RCCL
APRIL 2015
REVIEW OF CORNEA
& CONTACT LENSES
SPECIAL ISSUE
CONTACT LENS
COMPLICATIONS
Expert advice on diagnosing, treating
and—most of all—preventing problems.
• Bringing Clarity to CLARE
• Is That Corneal Infiltrate Sterile
or Infectious? EARN 1 CE CREDIT
• Special Care Keeps
Specialty Lens Wearers Safe
• Five Steps to Increase
Contact Lens Adherence
• Anti-VEGF for Corneal
Neovascularization
!
SAFETY
STRATEGIES
• Troubleshooting GP Lens Complications
ALSO
• Dry Eye: See It Through Their Eyes
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3/27/15 3:46 PM
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contents
Review of Cornea & Contact Lenses | April 2015
departments
4
News Review
Sclerals May Affect Corneal Nerves;
Age and Astigmatic VA: No Link
6
My Perspective
Getting Serious About OSD
By Joseph P. Shovlin, OD
7
Lens Care Insights
The Great Silicone Cover-Up
By Christine W. Sindt, OD
8
Derail Dropouts
Five Steps to Increase
Contact Lens Adherence
By Mile Brujic, OD, and
Jason R. Miller, OD, MBA
10
Pharma Science & Practice
Anti-VEGF in the Anterior Segment
By Elyse L. Chaglasian, OD,
and Tammy P. Than, OD, MS
30
GP Expert
Troubleshooting GP Complications
By Stephanie L. Woo, OD
32
Corneal Consult
Managing Acute Corneal Hydrops
in Keratoconus
By James Thimons, OD
34
features
12
16
20
24
Dry Eye:
See It Through Their Eyes
Patient questionnaires quantify the subjective
experience of the disease. Though vital
for research, are they worth using in your
practice?
By Aliza Martin, Associate Editor
Bringing Clarity to CLARE
Understanding and knowing how to treat
this common contact lens complication can
benefit both your patients and your practice.
By Lindsay A. Sicks, OD
Special Care Keeps
Specialty Lens Wearers Safe
Contact lens care is a vital step to the
continued safety and health of the contact lens
patient. So how does lens care differ in the
case of sclerals and other specialty lenses?
By Susan J. Gromacki, OD, MS
CE — Is that Corneal Infiltrate
Sterile or Infectious?
Out of the Box
Differentiating between the two requires close observation
and analysis. Here’s a results-oriented approach.
By Jeffrey Sonsino, OD, and Shachar Tauber, MD
Are You a Mentalist?
By Gary Gerber, OD
Cover design by Matt Egger
©iStock.com/Jobsonhealthcare
/ReviewofCorneaAndContactLenses
003_RCCL0415_TOC.indd 3
#rcclmag
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
3
3/27/15 3:40 PM
News Review
Sclerals May Affect Corneal Nerves
E
xtended wear of fluid-filled
scleral contact lenses may
change corneal nerve function in patients with certain diseases, according to research published
in the April 2015 Cornea.1
Researchers measured tear production, central corneal sensation,
sub-basal nerve density and tortuosity, and stromal nerve thickness
of 20 patients from the Prosthetic
Replacement of the Ocular Surface
Ecosystem (PROSE) treatment
program. Patients were divided
into two groups—distorted corneas (DC) or ocular surface disease
(OSD)—and evaluated before and
after 60 days of wear for a minimum of eight hours per day.
Researchers found basal tear
production significantly decreased
and corneal sensation increased
in patients with DC following
long-term wear of the PROSE
prosthetic device. In contrast, tear
production and corneal sensation
did not change in patients with
OSD. This difference, the researchers say, may be because patients
with DC have a healthier ocular
surface; thus, the intact lacrimal
functional unit (LFU) “responds
to the constant saline exposure by
reducing the basal tear production
and increasing corneal sensation, which are possible signs of
improvement in corneal disease.”
In contrast, “patients with OSD
did not have similar alterations in
LFU function possibly because of
ongoing inflammatory processes
disrupting the LFU.”
No significant change in subbasal nerve density and tortuosity
or stromal nerve thickness was
observed in either patient group.
• Corneal crosslinking may accelerate epithelialization and reduce length
and severity of necessary treatment in
moderate bacterial keratitis, according
to a study in the April 2015 Cornea.1
Researchers separated 32 bacterial
keratitis patients into two groups. The
control group was treated using standard medical therapy (i.e., lubrication,
fortified cefazolin (50mg/mL) every
hour, and systemic doxycycline every 12
hours following loading doses of fortified cefazolin and gentamicin) and the
case group was treated with CXL and
standard medical therapy. No statistically significant difference was noted
between the two groups one day following treatment, but researchers noted
the epithelial defects and the area of
infiltrates were both smaller in the CXL
group compared to the control group
by day seven following the beginning of
treatment.
1. Wang Y, Kornberg DL, St. Clair RM, et al. Corneal nerve structure and function after longterm wear of fluid-filled scleral lens. Cornea.
2015 April;34(4):427-32.
• Tobramycin can help prevent secondary corneal infections in patients wearing therapeutic soft contact lenses, says
new research published in the March
2015 Eye & Contact Lens.1
Researchers cultured 40 therapeutic
soft lenses of patients being treated for
recurrent corneal erosion following a
two-week wearing period. During wear
time, patients were treated four times
per day with topical tobramycin 3% and
topical sodium hyaluronate 0.1%. Upon
culturing, however, nine of the 40 lenses
yielded positive cultures, with Staphylococcus epidermidis identified as the
predominant organism. Methicillin-sensitive coagulase-negative staphylococci,
methicillin-resistant coagulase-negative
staphylococci, Enterobacter gergoviae
and Citrobacter freundii were also
isolated. No clinical signs of infectious
keratitis were found.
Age and Astigmatic VA: No Link
A
ge has no significant influence on visual acuity in the
presence of defocus and
astigmatic blur, reports a study
published in the March 2015 Optometry and Vision Science.1
Researchers dilated the right
eyes of 22 participants—12 young
adults and 10 older adults—using
cyclopentolate 1.0%, then provided each with artificial pupils
mounted on the back of a trial
lens. To evaluate visual acuity,
researchers simulated 13 blur
conditions using five spherical lens
conditions and two cross-spherical
lenses at four negative cylinder
axes. In each instance, participants were asked to read lines of
decreasing size of high-contrast
letters based on the Bailey-Lovie
4
IN BRIEF
chart through the center of the
artificial pupil. Following visual
acuity measurements, aberrations
were also measured.
Researchers found no significant
differences in visual acuity between the two age groups, disproving their hypothesis regarding
the older group experiencing less
decrease in visual acuity with blur;
accordingly, they reported no need
to test their second hypothesis that
variations between the two age
groups is explained by differences
in higher-order aberrations. However, they suggested further study
with more participants may yield a
different outcome.
1. Mathur A, Suheimat M, Atchison DA. Pilot
Study: Effect of Age on Visual Acuity with
Defocus and Astigmatism. Optom Vis Sci. 2015
Mar;92(3):267-71.
1. Bamdad S, Makelhosseini H, Khosravi A. Ultraviolet A/Riboflavin Collagen Crosslinking for Treatment of Moderate Bacterial Corneal Ulcers. Cornea.
2015 Apr;34(4):402-6.
1. Park YM, Kwon HJ, Lee JS. Microbiological
Study of Therapeutic Soft Contact Lenses Used in
the Treatment of Recurrent Corneal Erosion Syndrome. Eye Contact Lens. 2015 Mar;41(2):84-6.
Advertiser Index
Bausch + Lomb .................... Page 5
CooperVision ......Cover 2, Cover 3
Menicon .............................. Cover 4
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
004_rccl0415_news.indd 4
3/27/15 4:01 PM
Advertorial
Bausch + Lomb ULTRA® Contact Lenses
with MoistureSeal® Technology
A real no-brainer for my patients and my practice
by Dean Nolan
OD Private Practice
Lawton, Oklahoma
n my own practice my goal is to provide contact lens patients with the lens that is best for them.
These days, that means finding a lens that not only offers the best comfort and performance, but also
offers excellent value. In a relatively short time, the recently launched Bausch + Lomb ULTRA® contact
lens has become my “go to” lens in the monthly replacement category.
I
For many of my patients there’s a kind of “Ah hah” moment on
lens insertion; they find that with Bausch + Lomb ULTRA® contact
lenses they truly don’t feel the lens on their eye. When it comes to
lens selection, I encourage patients not to decide too quickly but
instead to take a couple of days in making up their minds. What
I’m finding is that even patients who have been refit in the last year
or so and are very happy with their current lens typically voice a
desire to go with the Bausch + Lomb ULTRA® contact lenses once
they’ve tried them.
I take time to explain to patients what’s behind the exceptional
comfort and performance that Bausch + Lomb ULTRA® contact
lenses offer, starting with oxygen transmissibility. I explain to patients
that the cornea needs oxygen to stay healthy, particularly for the
long wearing cycles and sustained visual demands of today’s digital
device users. With a Dk/t of 163, the Bausch + Lomb ULTRA®
contact lens has the highest oxygen transmissibility among the
leading monthly replacement lenses.1 Surprisingly, the lens also has
a low modulus, running counter to the long-held presumption that
an increase in Dk/t also meant an increase in modulus. In fact, the
Bausch + Lomb ULTRA® contact lens also has the lowest modulus
among the leading monthly replacement lenses.1 As a third
important component, the Bausch + Lomb ULTRA® lens also has
high water content (46%), so it’s also an extremely wettable lens.1
These physical properties are summarized in the table. Lastly, the
addition of aspheric optics combine to offer a lens with best in class
performance that my patients deserve.
Over the years, I have developed a reputation for offering my
patients the very best in cutting edge lens technology. I tell patients
to come back at no charge if the contact lenses they are wearing
1
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'LVWULEXWHGE\%DXVFK/RPED'LYLVLRQRI9DOHDQW3KDUPDFHXWLFDOV1RUWK$PHULFD//&%ULGJHZDWHU1-
‹%DXVFK/RPE,QFRUSRUDWHG%DXVFK/RPE8/75$DQG0RLVWXUH6HDODUHWUDGHPDUNVRI%DXVFK/RPE
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RCCL0415_BL Ultra Adv.indd 1
are not the absolute best they have ever worn. It’s been over seven
years since we have really had anything new to offer our patients in
monthly replacement contact lenses, so I find it very exciting to be
able to recommend an innovative, best in class lens that represents
a great value.
An important note: the level of innovation Bausch + Lomb ULTRA®
contact lenses bring to the monthly replacement category does not
come with an inherently expensive price tag: they are very affordable
to the patient. Beyond that, a $60 rebate is offered to patients who
order a 4-box annual supply of lenses; in effect, they get the last box
for free, effectively reducing the price per box—pretty exciting for
such a lens.
Comparison chart showing physical properties among leading
replacement lenses. High Dk/t, low modulus, high water content
and aspheric optics combine to give excellent overall performance.1
BRAND
Dk/t
MODULUS
163
70
46%
ACUVUE OASYS
147
73
38%
AIR OPTIX AQUA
138
102
33%
Biofinity
160
82
46%*
Bausch + Lomb ULTRA®
contact lenses
WATER
CONTENT
ASPHERIC
OPTICS
0HDVXUHGZDWHUFRQWHQW
about the author:
Dean Nolan, OD has practiced in his hometown of Lawton, Oklahoma
since being among one of the first graduates from Northeastern Oklahoma
College of Optometry in Tahlequah, and is a proud member of the
Oklahoma Optometry Association.
86=86D
SPONSORED BY
3/23/15 2:22 PM
My Perspective
By Joseph P. Shovlin, OD
Getting Serious About OSD
We have made huge strides in understanding dry eye disease, with more on the way.
H
ave you noticed the
new catch phrase,
“wellness of the
ocular surface”? It
heralds a change in
thinking that emphasizes routine
screening and maintenance in all
patients. Indeed, the most important part of an initial diagnostic
exam for lens wearers is an accurate
assessment of the ocular surface, as
many contact lens-related problems
can be blamed on an unstable tear
film, lid disease or overall poor
ocular surface health.
Fortunately, we’re now armed
with ways to assess and treat ocular
wellness. When I started in practice
three decades ago, artificial tears
were the mainstay of ocular surface
treatment, and sometimes the only
option for combating an issue. Our
inability to accurately diagnose the
problem was also a major impediment—for example, until recently
dry eye was mostly attributed solely
to aqueous deficiency. Now, however, we know that’s not the case.
Dry eye is a complex disease with
many interactions and cascades.
In the last four decades, researchers like James McCulley, MD, and
others have refined a classification
scheme based on research data. For
example, his work on lid disease
has led to the reclassification of posterior blepharitis into three broad
categories: hypersecretory MGD
(also called meibomian seborrhea),
hyposecretory MGD (either primary or obstructive) and turbid hypersecretory MGD. Other research
has revealed as many as 50% of all
patients with blepharitis co-present
with dry eye, likely because the
detergent effect on the lipid layer
6
alters epithelial cell membranes,
leading to cell death and inflammation—a possible contribution to an
aqueous-deficient dry eye.
POINT OF CARE OPTIONS
New in-office testing options have
also changed how we handle this
broad disease category by reducing
diagnosis time, improving patient
education and acting as a metric to
assess treatment effectiveness. In
addition to TearLab’s osmolarity
test, newer procedures include the
following:
• InflammaDry (RPS) provides
an assay of the proteolytic enzyme
matrix metalloproteinase 9 (MMP9). A marker for inflammation,
MMP-9 is a measure of epithelial
cell stress and is complementary to
measuring tear osmolarity; its real
value, however, is in identifying risk
and treatable problems that respond
to steroid and immunomodulator
therapy. We know that if the test is
negative for MMP-9, the patient’s
issue is not dry eye-related. The
opposite, however, is not true: a
positive response (i.e., >40ng/mL)
doesn’t serve as confirmation of dry
eye disease since there are many different conditions with an elevated
MMP-9 value.
• The TearScan MicroAssay offers two diagnostic tests: one detects
tear film lactoferrin content to
assess lacrimal gland function and
the other quantifies IgE to gauge
the allergic component of ocular inflammation. It has a relatively good
sensitivity in detecting an aqueousdeficient dry eye.
• One in 10 dry eye patients have
Sjögren’s syndrome. Unfortunately,
detection of conventional or tra-
ditional biomarkers for SS-A (Ro)
and SS-B (La) is only about 70%
sensitive in confirming a diagnosis.
Early diagnosis of Sjögren’s is critical, as its morbidity is troubling and
its link to lymphoma—including
non-Hodgkins lymphoma—is well
established. Now, other novel biomarkers such as salivary protein-1,
carbonic anhydrase-6, and parotid
secretory protein, instead offer extremely sensitive measures of early
Sjögren’s. They can be identified
using the Sjö test from Nicox.
Ongoing R&D involving secretagogues, IL-1 blocking anti-inflammatories, LFA-1 antagonists, selective glucocorticoid receptor agonists
and even androgen modulation
promise more treatment breakthroughs coming down the pike.
In the face of all these new developments, however, let us not forget
that decades ago our knowledge
and techniques, while crude, still
helped our patients achieve some
symptomatic relief. Assessing the
tear film, looking for debris and
meniscus height, staining the cornea
and conjunctiva and looking for lid
pathology helped shape our diagnostic decisions and treatment plans
then, and still have relevance today.
In closing, thank you to our
pioneers for paving the way and
asking the right questions that led
to the products we have today. I’m
certain anyone looking back decades from now will be as equally
amazed at the progress made
combating ocular surface disease,
particularly dry eye disease. We
look forward to the future work
that helps assess the “vital signs” of
ocular wellness that’s sure to come.
Stay tuned!
RCCL
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
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3/27/15 3:40 PM
Lens Care Insights
By Christine W. Sindt, OD
The Great Silicone Cover Up
A new lens surfacing option improves wettability and lubricity. How does it work?
I
t can be argued that the most
frustrating aspect of contact
lens practice isn’t determining the fit or the power, but
rather dealing with a nonwetting lens—it decreases clarity
and comfort and affects a patient’s
overall lens wearing experience.
Silicone-based materials are inherently hydrophobic, so any exposed
silicone in a lens has the potential
to be non-wetting. Additionally, in
some patients, excessive lipids in
the tear film may deposit onto the
lens to create a foggy, hydrophobic
surface. This issue can be reduced
by dispensing low-silicone-content
contact lenses; however, such lenses
also impede oxygen transmission,
increasing the chance for corneal
complications. Other solutions include switching lid hygiene regimens
and the most common method,
treating the lens with plasma.
THE 4th STATE OF MATTER
Plasma—ionized gas with an approximately equal number of positively
and negatively charged particles—is
neither completely a gas nor a liquid
but has properties similar to both.
It’s created by forming a vacuum in a
reaction chamber, then refilling with a
low-pressure gas such as oxygen.1
During contact lens treatment,
high-energy oxygen plasma bombards
the lens surface, transferring energy
from the plasma to it. This also cleans
and oxidizes the surface by creating
reactive species (i.e., free radicals, ions,
electrons, short-wavelength photons
and unstable oxygen species) that
react with water, altering the lens
surface to a hydrophilic state. This
effect occurs to depths of several hundred angstroms to 10µm without any
change to the bulk properties of the
lens material. Note that while plasma
treatment is superior to other options,
the hydrophilic result may last for only
a few minutes to several months.1
A NEWCOMER
Hydra-PEG (Ocular Dynamics) is a
polyethylene glycol
(PEG)-based polymer mixture that is
covalently (permanently) bonded to
the surface of the
Before (left) and after (right) Hydra-PEG treatment.
contact lens, effectively creating a wetting surface
comfort in patients suffering from
on the underlying lens material and
contact lens-induced dry eye.8
separating it from the ocular surface
Note: although it is a permanent
and tear film. PEG has been used in
coating, Hydra-PEG has only been
ocular lubricants for decades and
tested out to three months of simuis known to improve lens surface
lated rubbing/cleaning cycles. Ocuwettability, which improves tear
lar Dynamics currently recommends
breakup time, increases lubricity
hydrogen peroxide-based cleaners,
and reduces protein and lipid depobut reports it is also in the process
sition. Hydra-PEG can be applied
of testing multipurpose solutions for
to hydrogel, silicone hydrogel or GP compatibility.
lenses.
Thus far, my clinic experience
During application, the first step
with this product has been positive:
of lens surface preparation is either
I have found it creates a wettable,
the addition of a functional activaclear and comfortable surface, even
tor to the monomer mix or a short
in the most challenging of condiplasma surface treatment. Once
tions, such as lagophthalmos and
active, the lenses are then soaked
significant ocular surface disease. I
in the Hydra-PEG polymers during
anticipate Hydra-PEG will provide
the extraction/hydration step, or the another useful option in most conHydra-PEG polymers are added to
tact lens practices.
the blister pack during the autoclave
1. William Hoffman. Personal communication.
process.2 In either case, once the
2008.
active lens is placed in the PEG poly- 2. Ocular Dynamics. Hydra-PEG Manufacturing. Available at: www.oculardynamics.
mers, the Hydra-PEG permanently
com/#!manufacturing/c11sc. Accessed March 25,
2015.
bonds to the lens surface.
3. Measured via Captive Bubble Contact Angle.
In ex-vivo tests, Hydra-PEG
Ocular Dynamics data on file, 2014
4. Measured via Water Breakup Time. Ocular
was shown to improve wettability,
Dynamics data on file, 2014
surface water retention, lubricity
5. Measured via Digital Friction Evaluation. Ocular
Dynamics data on file, 2014
and deposit resistance.3-6 These lens
6. Measured via Radiolabeled Lysozyme Deposisurface properties have been corretion Assay. Ocular Dynamics data on file, 2014
lated with contact lens comfort in a
7. Jones, L. et al. “The TFOS International
on Contact Lens Discomfort: Report
number of studies.7 When applied to Workshop
of the Contact Lens Materials, Design, and Care
the Acuvue Oasys lens in a random- Subcommittee”. IOVS, October 2013, Vol. 54
8. Caroline, P. “Hydra-PEG: A Solution to Contact
ized controlled trial, Hydra-PEG
Lens Discomfort?” Poster presented at Global
Specialty Lens Symposium 2015.
surfaced lenses demonstrated good
RCCL
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
007_RCCL0415_LCI.indd 7
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3/27/15 3:41 PM
Derail Dropouts
By Mile Brujic, OD, and Jason Miller, OD, MBA
Five Steps to Increase
Contact Lens Adherence
Getting patients to comply with lens wear and care guidelines is a well-known battle.
Here are some points to make it a little easier.
R
ecent advances in
contact lens technology have given us a
host of new lens options in the realms of
presbyopic, toric and single vision
designs. Positive improvements
in contact lens care systems also
continue to provide additional
benefits to those who use them.
Together, these developments have
increased our arsenal of options to
re-engage with those contact lens
wearers who may have dropped
out in the past.
However, other reasons for
contact lens drop out still remain.
When a lens wearer abuses their
modality or care system, complications—although rare—can arise
as a result of non-adherence to
practitioner recommendations, a
common problem across all health
conditions, especially contact lens
care regimens.1 This month, we
share five highly effective ways to
better emphasize the importance
of adherence to your contact lens
patients. By increasing and tailoring our efforts, we improve our
patient’s chances of successfully
wearing contact lenses, which
will ultimately help keep them in
lenses long-term.
Be aware of how your
patients are caring for their
lenses. How often do contact lens
wearers walk into our practices
without any idea of which solution or rewetting drops—if any—
they are using? What about the
1.
8
condition of the patient’s contact
lens case? Certainly, migrating patients to a daily disposable contact
lens will help eliminate these potential issues, as they obviate the
need for care solutions and lens
cases. However, the patient may
still be using drops that you are
unaware of to alleviate comfort
issues.
So, how do you find out what
exactly your patients are doing to
care for their lenses? The answer
is fairly simple: ask them to bring
in their contact lens case, solution and any other care products,
as well as any drops they may be
using. Seeing them firsthand gives
us the opportunity to educate
patients on proper lens care if
needed and gives us the opportunity to intervene with appropriate clinical solutions if necessary,
including refitting them into a
daily disposable lens or suggesting
an alternate product.
Educate patients on how
to appropriately care for
their lenses. While proper lens
care is common knowledge for
the eye care practitioner, many
patients are not as educated
regarding its importance and influence. Surprisingly, even the most
seasoned contact lens wearers may
not know how to appropriately
care for their lenses. Try asking your contact lens patients to
explain their process for applying
and removing their contact lenses.
How do you educate these
2.
patients? Devise a consistent
conversation to have with all
contact lens patients and modify
it according to each patient’s
individual needs. Explaining the
importance of adherence and
correcting patient-specific errors
means they are more likely to
adhere to your guidelines. As an
example, you can say, “I want you
to be able to consistently wear
your contact lenses comfortably
and in a healthy way. This can
best be achieved by following our
recommendations on cleaning and
caring for your contact lenses.”
Next, follow this with the actual
steps necessary to care for the
lenses, and consider a discussion
of a daily disposable lens use.
If the patient has issues or
complications, show them.
Sometimes, patients will present
with symptoms caused by contact
lens abuse, such as GPC on the superior tarsal plate from lens overwear when deposits occur on the
lens surface and interact with the
lid while blinking.2 This response
leads to the clinically evident giant
papillae and, often, excessive mucus production. In these instances,
contact lens wearers typically seek
symptomatic relief—and delivering it will likely create a more
compliant lens wearer.3
But what about changes that are
less symptomatic, but still important to teach patients about? In
these cases, we often use slit lamp
imaging systems as an educational
3.
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
008_RCCL0415_DD.indd 8
3/27/15 3:42 PM
RCCL
REVIEW OF CORNEA
& CONTACT LENSES
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tool. For example, the patient who
is sleeping in hydrogel lenses, but
who is asymptomatic, may have
significant corneal neovascularization that can be imaged and
demonstrated. Or, someone who is
keeping their lenses in for longer
than prescribed who presents with
significant deposits on the lens
surface might benefit from seeing
those deposits up close. In either
case, imaging of these scenarios
helps the patient understand their
condition and hopefully, the need
for more compliant wear.
Give them the tools they
need. As practitioners, we
have heard almost every single excuse in the book for why our patients are noncompliant with their
replacement schedules. We have
made it a point to make it as easy
as possible for patients to remember to replace their contact lenses.
So, regardless of the modality, be
sure to give them the best tools
possible to help them remember
their replacement schedule.
Obviously, daily disposable
lenses are the easiest modality
to replace. It’s one of the main
reasons these lenses are associated with such a high level of
adherence.4 For patients wearing
two-week or monthly disposable
lenses, however, we need to guide
them to select a day or two days,
depending on the modality, as
their designated replacement day.
Depending on your practice,
you may also have the means to
provide patients with contact lens
cases, solution and other accoutrement to help with adherence.
4.
008_RCCL0415_DD.indd 9
Don’t assume non-adherence is the reason. A patient wearing contact lenses who
comes in with a corneal infiltrative
response is often immediately
assumed to be someone who has
abused their contact lenses. While
this is often the case, take caution
to consider other clinical entities
that may present similarly.
For example, a point-of-care test
such as AdenoPlus can be used
to rule out adenoviral keratoconjunctivitis in a contact lens wearer
presenting with an acute red eye
and corneal infiltrates.5 Clinically,
we will often pigeon-hole these
patients as contact lens abusers
when in fact they are contact lens
wearers who simply have another
etiology responsible for the cause
of their red eye.
It is well understood that adherence in health care is a constant
challenge. But by incorporating
these strategies, we can help influence contact lens adherence in a
positive way, reduce complications
and ultimately help those patients
who may discontinue lens wear
continue wearing their lenses successfully.
5. EDITORIAL STAFF
EDITOR-IN-CHIEF
Jack Persico jpersico@jobson.com
ASSOCIATE EDITOR
Aliza Martin amartin@jobson.com
CLINICAL EDITOR
Joseph P. Shovlin, OD, jpshovlin@gmail.com
EXECUTIVE EDITOR
Arthur B. Epstein, OD, artepstein@artepstein.com
ASSOCIATE CLINICAL EDITOR
Christine W. Sindt, OD, christine-sindt@uiowa.edu
CONSULTING EDITOR
Milton M. Hom, OD, eyemage@mminternet.com
SENIOR ART/PRODUCTION DIRECTOR
Joe Morris jmorris@jhihealth.com
GRAPHIC DESIGNER
Matt Egger megger@jhihealth.com
AD PRODUCTION MANAGER
Scott Tobin stobin@jhihealth.com
BUSINESS STAFF
PUBLISHER
James Henne jhenne@jobson.com
REGIONAL SALES MANAGER
Michele Barrett mbarrett@jobson.com
REGIONAL SALES MANAGER
Michael Hoster mhoster@jobson.com
VICE PRESIDENT OPERATIONS
Casey Foster cfoster@jobson.com
EDITORIAL BOARD
Mark B. Abelson, MD
James V. Aquavella, MD
Edward S. Bennett, OD
Aaron Bronner, OD
Brian Chou, OD
S. Barry Eiden, OD
Gary Gerber, OD
Susan Gromacki, OD
Brien Holden, PhD
Bruce Koffler, MD
Pete Kollbaum, OD, PhD
Jeffrey Charles Krohn, OD
Kenneth A. Lebow, OD
Kelly Nichols, OD
Robert Ryan, OD
Jack Schaeffer, OD
Kirk Smick, OD
Barry Weissman, OD
RCCL
1. Claydon BE, Efron N. Non-compliance in contact lens wear. Ophthalmic Physiol Opt. 1994
Oct:14(4):356-64.2. Elhers WH, Donshik PC.
Giant papillary conjunctivitis. Curr Opin Allergy
Clin Immunol. 2008 Oct;8(5):445-9.
3. Chigbu D. The management of allergic eye
diseases in primary eye care. Cont Lens Anterior Eye. 2009 Dec;32(6):260-72.
4. Dumbleton K, Woods C, Jones L, et al. Patient and practitioner compliance with silicone
hydrogel and daily disposable lens replacement
in the United States. Eye Contact Lens. 2009
Jul;35(4):164-71.
5. Sambursky R, Trattler W, Tauber S, et al.
Sensitivity and specificity of the AdenoPlus test
for diagnosing adenoviral conjunctivitis. JAMA
Ophthalmol. 2013 Jan;131(1):17-22.
REVIEW BOARD
Kenneth Daniels, OD
Desmond Fonn, Dip Optom M Optom
Robert M. Grohe, OD
Patricia Keech, OD
Jerry Legerton, OD
Charles B. Slonim, MD
Mary Jo Stiegemeier, OD
Loretta B. Szczotka, OD
Michael A. Ward, FCLSA
Barry M. Weiner, OD
3/27/15 3:42 PM
Pharma Science & Practice
By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD
Anti-VEGF in the Anterior Segment
Corneal neovascularization from contact lens overwear and other hypoxic events may
respond to this posterior segment therapy.
O
ne of the hallmarks
of the cornea is its
avascular, transparent nature, which
is a result of the precise composition and arrangement
of its constituent parts. A variety
of affronts—including infection,
inflammation, ischemia, degeneration and loss of the stem cell
barrier—can lead to the loss of this
avascularity in the form of corneal
neovascularization.1,2,
Over 1.4 million patients develop
corneal neovascularization each
year, with up to 12% of cases associated with subsequent decreased
acuity as immature and abnormal
vessels invade from the limbal
vascular plexus, causing scarring,
edema and inflammation.1,3 This
invasion occurs when the habitually
precise balance between pro- and
anti-angiogenic factors is disturbed
by an excess of pro-angiogenic factors.4
While a number of constituents
promote new vessel proliferation,
vascular endothelial growth factor
(VEGF) is one of the key regulators
of this process and, as such, has become an important target for medical therapy.5 Anti-VEGF treatments,
a mainstay of therapy for retinal
conditions, also hold promise for
corneal applications and may play a
particularly auspicious role in graft
survival after penetrating keratoplasty.2
A BETTER WAY?
Conventional therapy for corneal
neovascularization includes steroids,
thought to suppress activation and
10
Vessel encroachment into the cornea in a case of neovascularization due to
hypoxic stress. Might this be a patient who would benefit from anti-VEGF?
migration of macrophages, mast
cells, cytokines and other inflammatory cells promoting angiogenesis.2,6,7 Steroids are also often
used in combination with oral
matrix metalloproteinase (MMP)
inhibitors such as doxycycline in an
effort to regress abnormal corneal
vasculature. These techniques are
limited in efficacy, however, and
lead to well-known side effects of
topical steroids including cataracts
and glaucoma. Nonsteroidal antiinflammatory medications, photodynamic therapy, laser photocoagulation, fine needle diathermy and
conjunctival, limbal and amniotic
membrane transplantation have
also been used with varying success.2,6
Topical anti-VEGF therapy for
corneal neovascularization has been
investigated off-label using both
bevacizumab and ranibizumab,
which are monoclonal antibodies
against VEGF and traditionally
used for retinal indications.2,8,9
Both target VEGF-A, leading to
inhibition of abnormal blood vessel
formation and decreased vascular
permeability. Bevacizumab has been
used more often in off-label indications and in studies as a result of
its increased affordability. Bevacizumab was originally approved for
metastatic colorectal cancer, but has
long been used in ophthalmology
for off-label therapy of wet AMD,
proliferative diabetic retinopathy
and iris rubeosis.2,10
Therapy with anti-VEGF medications has been studied both in
subconjunctival and topical use and
has shown promise in the treatment
of herpetic keratitis, recurrent pterygium, corneal transplant rejection
and Stevens-Johnson syndrome.11
Multiple studies confirm the effectiveness of topical bevacizumab in
reducing corneal neovascularization
in experimental animal models, and
human use has shown significant
reductions in abnormal vasculature, even in patients recalcitrant
to traditional anti-inflammatory
therapies.2,6 Early treatment appears
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more efficacious in both animal and
human models, with both topical
and subconjunctival therapy.6,12,13
Chronic vascular conditions tend
not to respond as well to therapy as
active or acute angiogenesis.6,12
Clinically, corneal neovascularization can be seen after infectious, inflammatory and traumatic events.1,2
Inflammatory stress tips the balance
of growth and inhibitory factors
in favor of angiogenesis and leads
to the growth of new, abnormal
vasculature.4 The same can be seen
under hypoxic conditions, such as
contact lens overwear.2 The resulting neovascularization may be deep,
stromal or may present as superficial vascular pannus, depending
on the ocular insult.2,14 Deep and
stromal neovascularization may
be associated with interstitial and
disciform changes seen in herpetic
keratitis, while superficial changes
are typically associated with ocular
surface disease.2
Other bacterial, viral, protozoan
and fungal antigens may also induce
a keratitis that can lead to subsequent neovascularization. Trauma
(including chemical burns), ischemia
(i.e., limbal stem cell deficiency),
and inflammatory conditions may
also promote the abnormal vasculature.2,11,15 Autoimmune diseases
(e.g., Stevens-Johnson syndrome,
graft rejection and cicatricial
pemphigoid) and corneal degenerations (e.g., pterygium and Terrien’s
marginal degeneration) have further
been implicated in corneal neovascularization.2,11,15 Perhaps the most
widespread application, however,
lies in corneal transplantation,
where recipient neovascularization
before transplantation doubles the
FROM VEGF TO VESSELS
While there are a number of iterations of VEGF found throughout the
human body, VEGF-A is one of the
key regulators of hemangiogenesis in
ocular tissues.2 It is secreted by corneal
epithelial and endothelial cells, vascular endothelial cells and fibroblasts
and microphages found in scar tissue;
importantly, this process is exacerbated in inflamed and vascularized
corneas.6 Once released, it promotes
vascular endothelial cell proliferation,
migration and tube formation, and may
also play a secondary role in inflammation.1,6 Circulating VEGF exerts its
influence by binding to tyrosine kinase
receptors, which leads to a signaling
cascade promoting cell division and
proliferation of vessels.2
risk of graft rejection, and where
increases in graft survival after antiVEGF therapy have been demonstrated in animal models.2
GROWTH OPPORTUNITY
Clearly, there is a role for antiVEGF therapy in corneal neovascularization, and its potential anterior
segment indications are plentiful.
Areas for further research include
determining the ideal administration, route, dosage and formulation,
and whether a targeted combination therapy for multiple growth
factors is necessary to completely
regress vasculature in these patients.
While large, randomized studies
are required to firmly establish
the safety and breadth of corneal
indications, it seems clear that antiVEGF therapy will have an increasingly significant role in the management of corneal neovascularization
patients moving forward, and that
corneal specialists will have a more
efficacious tool at their disposal
when treating this potentially blinding condition.
The authors would like to acknowledge Stephanie Fromstein,
OD, for her invaluable contributions to this article.
RCCL
1. Chang JH, Gabison EE, Kato T et al. Corneal
neovascularization. Curr Opin Ophthamol. 2001;
12: 242-249.
2. Chang JH, Garg NG, Lunde E et al. Corneal neovascularization: an anti-VEGF therapy review. Surv
Opthalmol. 2012 ; 57(5): 415-429.
3. Lee P, Wang CC, Adamis AP. Ocular neovascularization: an epidemiologic review. Surv Ophthalmol. 1998; 43: 245-269.
4. Kvanta A. Ocular angiogenesis: the role of
growth factors. Acta Opthalmol Scand. 2006.; 84:
282-288.
5. Gan L, Fagerholm P, Palmblad J. Vascular
endothelial growth factor (VEGF) and its receptor
VEGFR-2 I the regulation of corneal neovascularization and wound healing. Acta Ophthalmol
Scand. 2004; 82: 557-563.
6. Papathanassiou M, Theodoropoulou S, Analitis A
et al. Vascular endothelial growth factor inhibitors
for the treatment of corneal neovascularization: a
meta-analysis. Cornea. 2013; 32(4): 435-444.
7. Phillips K, Arffa R, Cintron C et al. Effects of
prednisolone and medroxyprogesterone on corneal wound healing, ulceration and neovascularization. Arch Opthalmol. 1983; 101: 640-643.
8. Avila MP, Farah ME, Santos A et al. Three-year
safety and visual acuity results of epimacular
90strontium/90yttrium brachytherapy with bevacizumab for the treatment of subfoveal choroidal
neovascularization secondary to age-related
macular degeneration. Retina. 2011; 32(1): 10-18.
9. Krebs I, Lie S, Stolba U et al. Efficacy of intravitreal bevacizumab (Avastin) therapy for early and
advanced neovascular age-related macular degeneration. Acta Opthalmol. 2009; 87: 611-617.
10. Cheng SF, Dastjerdi MH, Okanobo A et al.
Short-term topical bevacizumab in the treatment
of stable corneal neovascularization. Am J Ophthalmol. 2012; 154: 940-948.
11. Ambati B. Corneal applications for anti-VEGF
agents. Adv Oc Car. 2011: 24-25.
12. Papathanassiou M, Theodossiadis PG, Liarakos
VS et al. Inhibition of corneal neovascularization by
subconjunctival bevacizumab in an animal model.
Am J Opthalmol. 2008; 145: 424-431.
13. Stephenson M. Anti-VEGF for CNV: questions
remain. Rev Ophthalmol. 2011. Published online
14. Ellenberg D, Azar DT, Hallak JA et al. Novel aspects of corneal angiogenic and lymphangiogenic
privilege. Prog Retin Eye Res. 2010; 29: 208-248.
15. Bock F, Konig Y, Kruse F et al. Bevacizumab
(Avastin) eye drops inhibit corneal neovascularization. Graefes Arch Clin Exp Ophthalmol. 2008;
246: 281-284.
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DRY EYE:
See It Through
Their Eyes
Patient questionnaires
quantify the subjective
experience of the disease.
Though vital for research,
are they worth using
in your practice?
D
ry eye is easily one
of the most common
diseases worldwide,
encompassing a
wide range of ocular
surface alterations with different
etiologies and pathophysiologies.1,2
In recent years, eye care practitioners have made great advances
in objectively measuring dry eye
with precision, using high-tech
tools to quantify tear osmolarity, inflammatory cytokines and
Sjögren’s biomarkers in addition
to familiar clinical evaluation tools
like the Schirmer’s test and tear film
breakup time. Methods to assign an
objective number or severity score
to dry eye have flourished.
But despite this success, the subjective component of the disease—
how it feels for patients—remains
for the most part poorly documented. Thus, it’s no surprise a number
of patient evaluation questionnaires
exist as part of an ongoing movement to quantify patient symptomatology. Dry eye questionnaires are
commonly used in clinical research
to screen participants, grade disease
severity and assess the effects of
treatments. They vary in length,
focus and extent of validation, and
often involve a number of rating
scales that are combined to produce
a total raw score (see “Comparing
Notes,” p. 14).13 So, how does one
determine which to use in a busy
12
By Aliza Martin, Associate Editor
clinical practice, especially given
that such questionnaires typically
measure patients against a pre-established clinical diagnosis of dry eye?
This article discusses some of the
more popular questionnaires available and examines their relevance in
the context of evaluating patients in
a clinical practice setting.
EXPERT TESTIMONY
In 2007, the International Dry Eye
WorkShop published a report on
the epidemiology of dry eye, which
evaluated the practicality of a
number of dry eye questionnaires.17
Requirements for consideration
included that the questionnaire had
been used in randomized clinical trials (RCTs) or epidemiologic
studies, had passed psychometric
testing and been deemed suitable
for evaluating general, non-disease
specific dry eye populations.17 Fourteen questionnaires met the criteria,
including five discussed here.
The committee identified characteristics that designate a questionnaire as suitable for use in epidemiologic studies and RCTs. First, it
must be able to detect and measure
changes in symptoms with effective treatment or disease progression.17 The recall period must also
be specified and the ability to set
a threshold of disease severity as
an inclusion criterion should be
present.17 Additionally, because of
the possibility of dry eye symptoms
worsening over the course of the
day, there must be a single, set time
for administering dry eye examinations and the questionnaire.17
The subcommittee recommended
adding a better definition of clinically meaningful changes in scores
as well as a better concept of the
“worst” symptom and a question
on visual function with respect to
dry eye.17 Also, more research on
the relationship between frequency
and severity of dry eye symptoms as
a means to better identify a clinically meaningful change in symptoms
is warranted.17
WHAT DO YOU USE?
Granted, dry eye questionnaires are
commonly used in clinical research
as a means to grade disease severity and assess treatment effects, all
within a controlled environment
with a pre-selected population segment. But are they useful in clinical practice, where many different
patients present who have not been
pre-sorted and who may fall within
a range of disease severity and treatment types and stages?
A validated questionnaire, says
Arthur B. Epstein, OD, provides
a good starting point to evaluate
the patient’s unique experience
and gather information about the
specifics of the disease. Dr. Epstein
is director of clinical research at
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Photo: Mile Brujic, OD
Does reliance on dry eye signs, like the
corneal staining above, overshadow
the role of the patient's symptomatic
experiences and quality-of-life issues?
Phoenix Eye Care and runs a dry
eye clinic at the practice. He uses
dry eye questionnaires to evaluate
every patient who walks in.
“I use questionnaires for documentation and especially for progress evaluations,” he says. “While
both are important, my personal
bias is to measure outcomes by a reduction in patients’ symptoms even
more than a reduction in physical
signs. Questionnaires provide a
standardized way of assessing how
well the patient is doing and if they
are responding to therapy.”
Dr. Epstein uses both the OSDI
and SPEED questionnaires, and says
each has its own benefits. “SPEED
is quicker, but OSDI provides a
bit more information. As odd as it
sounds, I haven’t totally settled on either, but I make sure we use the same
one we used previously to monitor
change” in a specific patient.
Overall, he adds, the usefulness of
the different dry eye questionnaires
varies depending on the patient.
“For example, the CLDEQ is
optimized for lens wearers, and the
DEQS focuses more on quality-oflife issues. Some are research tools
and less useful in clinical practice.”
Al Kabat, OD, and Whitney
Hauser, OD, of Southern College
of Optometry’s TearWell Advanced
MMP-9 testing,” he says. “We can
Dry Eye Treatment Center in Mem- also assess treatment response by
phis, also use the OSDI and SPEED
following the patient’s symptomatic
questionnaires for similar purposes.
improvement on the questionnaire.”
Because both are validated and
used in the practice together, they
DIY EFFORTS
act as a good system of checks and
Some practitioners choose to create
balances. “We use the questiontheir own dry eye questionnaire.
naires to first quantify the patient’s
In addition to using the SPEED
symptoms as a finite entity, and
questionnaire, Paul M. Karpecki,
then track the patient’s progress as
OD, of Koffler Vision Group in
we perform or initiate specific treat- Kentucky, also uses a custom one of
ment regimens,” Dr. Kabat says.
his own making (shown below).
“Occasionally, patients are in“The second is a much more
fluenced by how they feel on a
extensive questionnaire about dry
particular day, and the surveys
eye disease that is administered on a
provide a more global view,” adds
clipboard when the patient is placed
Dr. Hauser. “Dry eye care, unlike
in the exam lane waiting on the
many other eye diseases, is driven
doctor,” he says. Contrary to the
by symptom relief, and the surveys
SPEED questionnaire, which is used
give a measureable indication of
on every patient, the custom form is
improvement.”
only used for new patients referred
specifically for dry eye disease evalThe responses from the dry
uations. “The SPEED questionnaire
eye questionnaires do have a big
initiates a potential dry eye patient
influence on treatment decisions,
workup,” says Dr. Karpecki. “The
Dr. Kabat says. “For a severely
extensive custom questionnaire
symptomatic patient, we are more
actually predicts potential diseases
apt to initiate aggressive therapy
ranging from anterior blepharitis to
even in lieu of significant findings.
Likewise,
se,, for a patient with less
symptomology,
we might be more
m
mology,
conservative
vattive in our treatment
algorithm.”
hm
m.”
Eric
Donnenfeld,,
MD,
a Long
Island ophop
phthalmologist
loggist
who specialeccializes in catacattaract and
d refracr
tive surgery,
geery,
uses OSDI
SD
DI and
SPEED to
o guide
diagnostic
stic testing.
Dry eye questionnaires can also
“All patients
tieents who
be custom-made, such as this one from
have positive
osiitive findings
Paul M. Karpecki,
p
, OD. To download a copy
py
on the questionnaire
ti
i
of it suitable for use in your practice, look for
this article at www.reviewofcontactlenses.com.
undergo osmolarity and
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DRY EYE: SEE IT THROUGH THEIR EYES
Comparing Notes: Selected Dry Eye Evaluation Forms
The options for documenting the patient’s experience of dry eye range from simple one-page
sheets with three key components to a complete soup-to-nuts account of their case history.
Here’s a quick overview of several popular ones. To find links to these forms, snap a picture of
the QR code on the right with your smartphone or visit www.reviewofcontactlenses.com.
• McMonnies Questionnaire. Arguably the first modern dry eye questionnaire, the McMonnies
is comprised of 14 items that focus on established risk factors for dry eye including age, sex, contact lens
wear, medication use and certain systemic and ocular factors.5 The questionnaire was intended to both
determine the presence of dry eye and identify individuals at risk for developing the disease.
Several studies validating the McMonnies questionnaire as a means to screen patients for dry eye disease
exist.6,7 A separate study evaluating the psychometric properties—reliability, validity and accuracy—of it reported poor internal consistency, moderate test-retest reliability and fair concurrent validity and accuracy.8
The McMonnies questionnaire appears on p. 15.
• Dry Eye Questionnaire (DEQ) and Contact Lens Dry Eye Questionnaire (CLDEQ). Both versions of
the DEQ include categorical scales to measure prevalence, frequency, diurnal severity and intrusiveness of
common ocular surface symptoms in a typical date of a one-week recall period. Participants are asked to
indicate “never, infrequent, frequent or constant” with regard to frequency and intensity of comfort, dryness, visual changes, soreness and irritation, grittiness and scratchiness, burning and stinging, foreign body
sensation, light sensitivity and itching.9
The two questionnaires also include questions on the perceived time of day that symptoms worsen, how
much the symptoms affect daily activities, computer use, use of systemic and ocular medications, and
presence of allergies.9 The DEQ has been successfully evaluated for its use in measuring the frequency and
intensity of symptoms of ocular irritation in patients with aqueous tear deficient dry eye.10
• Ocular Surface Disease Index (OSDI). Developed by the Outcomes Research Group at Allergan, the
OSDI questionnaire is a self-administered 12-question scale designed to assess a range of ocular surface
symptoms, their severity and impact on visual function in a one-week recall period.11 Currently, the OSDI is
one of only two validated dry eye questionnaires to include quality-of-life measures for clinical use.12
• Subjective Evaluation of Symptom of Dryness (SESoD). The SESoD is a three-item questionnaire
created by Allergan to evaluate a patient’s perception of ocular discomfort related to dryness. Together
with the DEQ, McMonnies and OSDI, the SESoD has been shown to exhibit unidimensionality—that is, it is
comprised of questions that measure specific metrics simply and linearly to yield straightforward values.13
For example, income is a unidimensional variable; socioeconomic status, which includes income, occupation and education, is a multidimensional variable.
• Impact of Dry Eye on Everyday Life (IDEEL). The 57-question IDEEL survey from Alcon assesses the
effect of dry eye with respect to three primary modules: dry eye symptom bother, impact on daily life
(comprising impact on daily activities, emotional state and work) and treatment satisfaction (comprising
patient attitude towards treatment effectiveness and treatment-related bother/inconvenience).14 Together
with the OSDI questionnaire, the IDEEL survey comprises a small category of dry eye questionnaires that
include quality-of-life measures for clinical use.12
A psychometric analysis performed as part of a validation study involving 210 subjects—130 with nonSjögren's keratoconjunctivitis sicca, 32 with Sjögren's syndrome and 48 controls—found IDEEL to exhibit
good consistency and reliability.14 Strong correlation between IDEEL and the Dry Eye Questionnaire was
also noted.14
• Standard Patient Evaluation of Eye Dryness (SPEED). The SPEED questionnaire is a four-question survey developed by TearScience to assess frequency and severity of patient dry eye symptoms. In particular, it monitors diurnal and longer-term symptom changes over the course of three months.15 The SPEED
questionnaire has been shown to exhibit good validity, unidimensionality, objectivity and consistency when
compared with the DEQ, McMonnies questionnaire, OSDI and SESoD.15
• Dry Eye-Related Quality-of-Life Score Questionnaire (DEQS). The DEQS is a 15-item questionnaire
created to assess the presence of dry eye symptoms and their severity, and the effects of these symptoms
on aspects of patients’ everyday lives, including psychological and social aspects.16 A psychometric analysis
found the study had good internal consistency, test-retest reliability, discriminant validity and responsiveness to change; thus, the test is valid and reliable for evaluating the multifaceted effect of dry eye disease
on a patient’s daily life.16
14
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McMonnies Dry Eye Questionnaire
Please answer the following by underlining the responses most appropriate to you:
Female / Male
(0)
Age: less than 25 years
years(M2/F6)
(M1/F3)
/ 25-45 years
/ more than 45
Currently wearing: no contact lenses / hard contact lenses /
soft contact lenses
1. Have you ever had drops prescribed or other treatment
for dry eyes?
Yes(6) / No(0) / Uncertain(0)
2. Do you ever experience any of the following eye
symptoms?
1. Soreness 2. Scratchiness 3. Dryness
4. Grittiness 5. Burning
3. How often do your eyes have these symptoms?
Never(0) / Sometimes(1) / Often(4) / Constantly(8)
4. Are your eyes unusually sensitive to cigarette smoke,
smog, air conditioning, or central heating?
Yes(4) / No(0) / Sometimes(2)
5. Do your eyes become very red and irritated when
swimming?
Not applicable(0) / Yes(2) / No(0) / Sometimes(1)
6. Are your eyes dry and irritated the day after drinking
alcohol?
Not applicable(0) / Yes(4) / No(0) / Sometimes(2)
7. Do you take: antihistamine tablets(2) or use antihistamine
eye drops(2), diuretics (fluid tablets)(2), sleeping tablets(1),
tranquillizers(1), oral contraceptives(1), medication for
duodenal ulcer(1), digestive problems(1), high blood
pressure(1), antidepressants(1) or ___________________?
(Write in any medication you are taking that is not listed.)
8. Do you suffer from arthritis?
Yes(2) / No(0) / Uncertain(0)
9. Do you experience dryness of the nose, mouth, throat,
chest or vagina?
Never(0)/ Sometimes(1) / Often(2) / Constantly(4)
10. Do you suffer from thyroid abnormality?
Yes(2) / No(0) / Uncertain(0)
11. Are you known to sleep with your eyes partly open?
Yes(2) / No(0) / Sometimes(1)
12. Do you have eye irritation as you wake from sleep?
Yes(2) / No(0) / Sometimes(1)
Scores: Normal (< 10) Marginal dry eye (10 - 20) Pathological dry eye (>20)
From: McMonnies C, Ho A: Patient history in screening for dry eye conditions. J Am Optom Assoc 1987, 58(4):296–301.
dry eye to allergic conjunctivitis. It
also triggers various treatment options.” Also, its short length allows
patients to feel like they are making
the best use of their time.
Dr. Karpecki created a custom
questionnaire because he felt he
“needed more information and
didn’t want to have to rely on my
memory to ask the right questions
of the patient.” It’s a culmination of
his 20 years’ experience running a
dry eye clinic plus information from
research papers and dry eye studies.
Another option is to adapt an
existing questionnaire or two. John
D. Sheppard, MD, president of Virginia Eye Consultants, uses both the
OSDI and SPEED questionnaires,
but says “both ask a little less than
we’d like to differentiate the different types of ocular surface disease.
We all think about dry eye, which
is ubiquitous, but also extremely
common are MGD and blepharitis
as well as ocular allergy.”
Patients who present at Dr.
Sheppard’s practice take a modified
version of the SPEED questionnaire.
“A good supplemental question to
ask on the SPEED is, ‘Do your eyes
itch?’ Answer choices include: Infrequently; frequently; all the time;
it’s driving me crazy. Itching is an
important symptom that overlaps
between the three most common
ocular surface conditions but
focuses most on ocular allergy,” Dr.
Sheppard says. “Another question
that seems to help with blepharitis
is, ‘Are your eyelids red?’ with the
same frequency qualifiers. Also,
‘Are your eyes burning?’ Burning
seems to be something that helps
with identifying blepharitis. You
can also ask patients about crusting
and matting on their lids as well.”
THE IDEAL
What might the ideal dry eye
questionnaire look like? Dr. Epstein
says SPEED comes closest. “It’s
free, it’s quick, it’s repeatable and it
should be used consistently with all
dry eye patients. It is also an excellent tool for uncovering dry eye
among patients who are ‘silent sufferers’ and don’t realize they have a
problem that can be effectively—or
more effectively—managed.”
Dr. Kabat agrees about the basic
principles of an ideal questionnaire
and that the SPEED is one such
example, but also offers a more
general set of characteristics. “If
the questionnaire takes more than
three minutes for the patient to
complete, then it is impractical. If
it takes more than one minute to
score, then it is impractical. If it
cannot be administered and scored
by a technician or assistant, then it
is impractical,” he says. “For the
physician, there should be no more
of a time commitment than glancing at the number and assessing its
value relative to the scale.”
(Continued on p. 19)
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Bringing Clarity
TO CLARE
Understanding and knowing how to treat this common contact lens
complication can benefit both your patients and your practice.
By Lindsay A. Sicks, OD
T
he clinical entity
known as contact
lens-induced acute red
eye, or CLARE, is an
inflammatory reaction
of the cornea and conjunctiva
associated with overnight contact
lens wear. It is also commonly
referred to as acute red eye or
tight lens syndrome. Often,
the patient will present to your
practice wearing dark sunglasses
or clutching a box of tissues
in an effort to cope with their
symptoms. While treatment
is relatively straightforward,
episodes of this condition can
recur; thus, our job as clinicians is
not only to treat the condition in
its acute stage, but also to educate
the patient and give them the
tools to return to lens wear in the
healthiest possible manner.
SIGNS AND SYMPTOMS
CLARE is typically characterized by sudden onset of unilateral
eye pain, photophobia, epiphora
and ocular irritation. Accompanying slit lamp signs include
diffuse conjunctival and limbal
hyperemia, as well as the presence of multiple corneal epithelial
and subepithelial infiltrates. The
infiltrative reaction is generally
located in the corneal periphery
and mid-periphery; when sodium
fluorescein stain is instilled in the
16
eye, the infiltrative areas do not
typically exhibit overlying punctate staining, indicating minimal
epithelial involvement.3,4 In more
severe cases of CLARE, corneal
edema or anterior uveitis may also
be present, although these signs
are not common.1,2 Visual acuity is
usually unaffected.
It is prudent to ask patients
presenting with CLARE symptoms
about any recent illnesses, including symptoms of the common
cold such as headache, fatigue and
runny nose. Often, upper respiratory tract infections are associated
with gram-negative organisms like
Haemophilus influenza.1,2 One
study found that patients who
were colonized with H. influenzae were more than 100 times as
likely to have had a CLARE or
infiltrative response than those
subjects who were not colonized
with this bacterium.5
CASE HISTORY
AND EVALUATION
Typically, the most reliable way
to accurately diagnose CLARE
is with a complete case history
and assessment of the symptoms
mentioned above. By definition, CLARE is associated with
sleeping while wearing contact
lenses.2,3 This can be anything
from a short afternoon nap to a
full night of extended wear—the
fact that the eye is closed for an
extended period of time is key to
our diagnosis. So, consider asking
all your contact lens patients how
many times per week they sleep or
nap in their lenses as part of your
routine history sequence.
Knowledge of the patient’s
habitual lens type and wearing
schedule may also have some
value in our diagnostic considerations. Conventionally, CLARE
is associated with tight fit or poor
movement of extended-wear, low
oxygen permeability, high water
content hydrogel lenses. However,
note that CLARE can also be
caused by extended wear of silicone hydrogel lenses, which have
significantly risen in market share
in the United States in the last decade.1,6 CLARE has been reported
to occur in 34% of continuous
wear hydrogel lens patients and
less than 1% of silicone hydrogel
extended wear patients.7-9 Reports have also linked CLARE to
ABOUT THE AUTHOR
Dr. Sicks is an assistant
professor at Illinois College
of Optometry in Chicago.
She is involved in the
contact lens didactic
curriculum and also serves
as a clinical attending
physician in the Illinois Eye Institute’s
Cornea Center for Clinical Excellence.
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extended wear gas permeable (GP)
lenses, high oxygen permeability silicone elastomer lenses and
overwear of daily disposable soft
contact lenses.10
In the absence of a lens fit evaluation, history questions regarding
hours per day of lens wear and
difficulty with lens removal at the
end of the day may assist in diagnosis. If you are able to assess the
lens on-eye, pay special attention
to lens movement and push-up
test results. Note, however, that
there are reported cases of CLARE
occurring with well-fit contact
lenses showing adequate movement.10,11
cells, and then infiltration of the
injured tissue by polymorphonuclear leukocytes and other cells.
This collection of inflammatory
cells within the cornea forms what
we call an infiltrate. The result is
CLARE and its associated signs
of conjunctival hyperemia and
corneal epithelial and subepithelial
infiltrates.7
DIFFERENTIAL DIAGNOSIS
In a case that may be CLARE or
another corneal infiltrative event
(CIE), the most important element
to consider is whether the presenting condition is infectious or
non-infectious.
moderate to severe pain symptoms
that worsen with lens removal.
Anterior chamber cells and flare
and mucopurulent discharge
are more common in MK than
CLARE and CLPU.3 A positive
bacterial culture or the presence
of tear film exudate can also help
make an MK diagnosis.
CLARE can also appear similar
to conditions like contact lensinduced peripheral ulcer (CLPU)
and infiltrative keratitis (IK).3
However, while CLARE typically
presents with multiple small focal
and diffuse infiltrates that do not
stain with fluorescein, CLPUs are
characterized as single circular
ETIOLOGY
While the etiology of
CLARE is not completely
understood, it is generally
classified as an inflammatory event of the cornea
and conjunctiva. General
risk factors include wear
of high water content
lenses, wear of tight fitting
lenses and history of a
recent upper respiratory
tract infection.2
One commonly cited
cause of CLARE is coloniAcute contact lens-associated red eye presentation in a 28-year-old Indian male.
zation of the lens surHe noted associated blurry vision, foreign body sensation and photophobia.
face with gram-negative
After a 10-day course of tobramycin/dexamethasone suspension QID and
preservative-free artificial tears every hour for relief, he reported a significant
bacteria, specifically H.
improvement in symptoms. (Case and photo courtesy of Kelli Theisen, OD.)
influenzae, Pseudomonas
aeruginosa and Serratia
Due to its sight-threatening pomarcescens.12 An inflammatory
focal infiltrates up to 2mm in
response is triggered by endotoxtential if left untreated, microbial
diameter that pick up fluoresins released by the breakdown
keratitis (MK) should be high on
cein stain. IK is associated with
of bacterial cell walls. The conthe list of differentials in any conStaphylococcal hypersensitivity
dition is worsened in the tight
tact lens wearer presenting with a
and may occur in one or both eyes
lens environment because of lens
red eye. To differentiate MK from
showing multiple small infiltrates
dehydration, minimal lens moveother CIEs, look for a discrete
with or without corneal staining.
ment, decreased tear exchange and area of fluorescein staining, typiA careful history and slit lamp
hypoxia.1,7,10,12,13
cally greater than 1mm diameter
examination can help guide your
In the inflammatory process,
and often located in the central
diagnosis.
limbal vasodilation occurs, folcornea. There may also be lid
The remaining CIEs are catlowed by release of white blood
edema, a reactive ptosis, and more egorized as asymptomatic and
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BRINGING CLARITY TO CLARE
clinically insignificant.3 Asymptomatic infiltrative keratitis (AIK)
and asymptomatic infiltrates (AI)
are simply differentiated from
CLARE in that they are seen on
physical exam but carry no entering complaints. Other differentials
to consider include: chlamydial
conjunctivitis, trachoma, adenoviral infection, epidemic keratoconjunctivitis, Staphylococcal
marginal keratitis, Thygeson's
superficial punctate keratitis and
herpes simplex keratitis.14
TREATMENT AND
MANAGEMENT
Management of CLARE always
begins with discontinuation of
contact lens wear. Beyond that,
the condition is often self-limiting
and may not require therapeutic
intervention—in many cases,
palliative treatment with artificial
tears will suffice. However, we
often prescribe additional therapeutic options to promote healing
and improve patient comfort. Depending on severity, the infiltrates
can take days to weeks following
cessation of lens wear to heal.
Since many of the signs and
symptoms of CLARE mimic those
of microbial keratitis, it is prudent
to instill sodium fluorescein and
assess the corneal integrity for any
epithelial disruption. Typically,
there is minimal to no epithelial
disruption with CLARE; however,
if there is corneal staining present
in association with an infiltrate,
the diagnosis no longer clear-cut
and the lesion becomes suspicious
for MK. In such cases, conservative management warrants using
a topical antibiotic for at least the
first 48 hours of treatment. Some
practitioners may prefer to address both the inflammation and
risk of infection as quickly as possible by prescribing a combination
18
topical antibiotic/steroid from the
start. Recommended follow-up is
daily until signs of improvement
are shown.
In cases where the photophobia
is particularly symptomatic, or
where there is an accompanying
anterior uveitis component, application of a topical cycloplegic
agent is warranted for at least the
first 24 hours. Topical and oral
NSAIDs are also effective adjunct
treatment options to quell the
discomfort. If cells and flare persist, consider addition of a topical
steroid to the regimen.
After complete healing, patients
can resume lens wear using a
fresh lens right out of the vial or
blister pack. Consider changing
lens fit, material, modality and/
or replacement schedule prior
to resuming lens wear to reduce
potential for reoccurrence. For
example, if the habitual lens was
a tight fit, try selecting different
base curve or diameter to improve movement and centration.
If the patient has a history of lens
abuse or overwear, switch them
to a daily disposable lens design
instead. Also, consider refitting
patients into GP lenses—patients
with a history of soft lens complications often adapt well to GP
lenses and appreciate the benefits
they provide.
It is important to note that
recurrence of inflammatory
complications can happen in
50% to 70% of wearers who
resume hydrogel extended wear
after resolution of their initial
episode of CLARE.15 Additionally,
patients who have had a CLARE
episode retain higher levels of limbal injection, bulbar injection and
conjunctival staining afterwards
compared with controls.9 Careful slit lamp examinations and
shorter intervals between contact
lens appointments following a
CLARE episode may be the best
practice to follow based on your
clinical judgment.
Above all, patient education plays an important role in
preventing corneal infiltrative
events such as CLARE. Stressing
the importance of appropriate
lens replacement, wear and care
schedules to all of your contact
lens patients can promote better
patient adherence to our recommendations.
Patients should be advised to
stop wearing their lenses while ill
and when lens wear is uncomfortable or painful, particularly while
their eyes are closed. For patients
who have had a CLARE episode,
emphasizing the risk of recurrence
as well as a review of symptoms to
look out for may also be helpful.
Be sure to also provide an easy
way for patients to contact your
office in case of an emergent issue
so that they end up in the best
hands possible should another
complication occur.
RCCL
Coding for CLARE
Currently, there is no exact
match in ICD-9 nomenclature
for CLARE, and it does not
appear that ICD-10 will have
any additional entries that are
more appropriate. As such,
one should continue to report CLARE using a symptom
code appropriate to the chief
complaint, such as those for
eye pain, redness of the eyes
or epiphora. If there is an accompanying corneal infiltrate,
additional codes for central
and peripheral corneal opacity would also be appropriate. Other applicable options
may include anterior uveitis,
viral conjunctivitis or corneal
edema codes, depending on
the case.
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1. Dumbleton K, Jones L. Extended and Continuous Wear. in Clinical Manual of Contact Lenses. E.
Bennett and V. Henry, Eds. Williams and Wilkins.
2008:410-443.
2. Stapleton F, Keay L, Jalbert I and Cole N. The
epidemiology of contact lens related infiltrates.
Optom Vis Sci. 2007;84(4):257-272.
3. Sweeney DF, Jalbert I, Covey M, et al. Clinical
characterization of corneal infiltrative events
observed with soft contact lens wear. Cornea.
2003;22(5):435-442.
4. Sankaridurg PM, Holden BA, Jalbert I. Adverse
events and infections: which ones and how
many? In e. Sweeney D, Silicone Hydrogels:
Continuous Wear Contact Lenses (pp. 217-274).
Oxford: Butterworth-Heinemann.
5. Sankaridurg PR, Willcox MD, et al. Haemophilus
influenzae adherent to contact lenses associated
with production of acute ocular inflammation. J
Clin Microbiol. 1996;34(10):2426-2431.
6. Nichols JJ. Annual Report: Contact Lenses
2013. Contact Lens Spectrum;29(January
2014):22-28.
7. Zantos SG, Holden BA. Ocular Changes
Associated with Continuous Wear of Contact
Lenses. The Australian Journal of Optometry.
1978;61(12):418-26.
8. Nilsson, S. Seven-day extended wear and 30day continuous wear of high oxygen transmissibility soft silicone hydrogel contact lenses: a
randomized 1-year study of 504 patients. CLAO
J. 2001;27(3):125-36.
9. Stapleton F, Keay L, Jalbert I, Cole N.
Altered Conjunctival Response After Contact
Lens–Related Corneal Inflammation. Cornea.
2003;22(5):443-7.
10. Sankaridurg PM, Vuppala N, Sreedharan A,
et al. Gram negative bacteria and contact lens
induced acute red eye. Indian J Ophthalmol,
1996;44(1):29-32.
11. Crook, T. Corneal infiltrates with red eye related to duration of extended wear. J Am Optom
Assoc. 1985;56(9):698-700.
12. Holden BA, La Hood D, Grant T, et al. Gramnegative bacteria can induce contact lens related
acute red eye (CLARE) responses. CLAO J.
1996;22(1):47-52.
13. Binder PS. The physiologic effects of extended wear soft contact lenses. Ophthalmology.
1980;87(8):745-9.
14. Robboy MW, Comstock TL, Kalsow CM. Contact Lens-Associated Corneal Infiltrates. CLAO J
2003;29(3):146-54.
15. Sweeney DF, Grant T, Chong MS, et al. Recurrence of acute inflammatory conditions with
hydrogel extended wear. Invest Opthalmol Vis
Sc 34:S1008.
DRY EYE: SEE IT THROUGH THEIR EYES
(Continued from p. 15)
Additionally, Dr. Kabat says, it
should assess symptom impact on
lifestyle and provide a metric for
quantifying symptom severity, and
should have the ability to be used
“as a screening tool for all patients
in a practice with interest in dry eye
management, or as part of the data/
history collection in a specialty dry
eye practice.”
The ideal dry eye questionnaire
should also cover certain symptoms.
“Key symptoms must be included
such as blurred or transient blurred
vision, dryness/grittiness, irritation,
burning and watering,” Dr. Karpecki says, and also include severity,
frequency and which eye drops are
currently being used.
Dr. Donnenfeld adds, “We want
to know the patient’s ability to
function at normal tasks.”
Dr. Sheppard envisions the development of something more technologically advanced. “I would have a
questionnaire that the patient could
fill out at home in a reproducible
format that we could then plug in
digitally when they walk into the
office with essentially no effort on
the part of the technician,” he says.
“The information would then appear as a global score on the chart,
with maybe a bar graph read-out
that tells us this is aqueous deficiency, this is lipid deficiency, this is
blepharitis, this is allergy.” Historical data could then portray the progression or resolution of important
complaints in one readout, he says.
Ultimately, the choice of which—
if any—dry eye questionnaire
depends on practitioner preference.
But no matter what, “providing
surveys to patients about their
symptoms demonstrates a sense of
empathy for their condition that
many practitioners fail to do,”
Dr. Hauser says. “Often, dry eye
patients feel as if they are relegated
to an afterthought by their doctors.
The patients recognize that their activities of daily living have been inhibited, if not devastated, by ocular
surface disease, and they appreciate
the attention to their plight.”
RCCL
1. Gayton JL. Etiology, prevalence and treatment of dry eye disease. Clin Opthalmol. 2009;
3:405-12. www.ncbi.nlm.nih.gov/pmc/articles/
PMC2720680/
2. Savini G, Prabhawasat P, Kojima T, et al. The
challenge of dry eye diagnosis. Clin Ophthalmol.
2008 Mar;2(1):31-55.
3. Bjerrum KB. Test and symptoms in keratoconjunctivitis sicca and their correlation. Acta
Ophthalmol Scand 1996;74:436–41.
4. Hay EM, Pal TB, et al. Weak association between
subjective symptoms of and objective testing for
dry eyes and dry mouth: results from a population
based study. Ann Reum Dis 1998;57:20–4.
5. McMonnies CW. Key questions in a dry eye history. J Am Otpom Assoc. 1986 Jul;57(7):512-7.
6. McMonnies CW, Ho A. Patient history in screening for dry eye conditions. J Am Optom Assoc.
1987;58:296-301.
7. McMonnies CW, Ho A. Responses to a dry eye
questionnaire from a normal population. J Am
Optom Assoc. 1987:58:588-591.
8. Nichols KK, Nichols JJ, Mitchell GL. The reliability and validity of McMonnies Dry Eye Index.
Cornea. 2004 May;23(4):365-71.
9. Begley C, Chalmers RL, Mitchell GL et al. Characterization of Ocular Surface Symptoms from
Optometric Practices in North America. Cornea
2001;20(6):610-18.
10. Begley CG, Caffery B, Chalmers RL, et al. Use of
the Dry Eye Questionnaire to Measure Symptoms
of Ocular Irritation in Patients with Aqueous Tear
Deficient Dry Eye. Cornea 2002;21(7):664-70.
11. Walt JG, Rowe MM, Stern KL. Evaluating the
functional impact of dry eye: the Ocular Surface
Disease Index [abstract]. Drug Inf J. 1997;31:1436.
12. Grubbs JR Jr, Tolleson-Rinehart S, Huynh K, Davis RM. A review of quality of life measures in dry
eye questionnaires. Cornea. 2014 Feb;33(2):215-8.
13. Simpson TL, Situ P, Jones LW, et al.. Dry eye
symptoms assessed by four questionnaires. Optom Vis Sci. 2008;85:692–699.
14. Espindle D, Simpson T, Nelson J, et al. Development and validation of the impact of dry eye on
everyday life (IDEEL) questionnaire, a patientreported outcomes (PRO) measure for the assessment of the burden of dry eye on patients. Health
Qual Life Outcomes. 2011 Dec 8;9:111.
15. Ngo W, Situ P, Keir N, et al. Psychometric
properties and validation of the Standard Patient
Evaluation of Eye Dryness questionnaire. Cornea.
2013;32(9):1204-10.
16. Sakane Y, Yamaguchi M, Yokoi N, et al. Development and validation of the Dry Eye-Related
Quality-of-Life Score questionnaire. JAMA Ophthalmol 2013 Oct:131(10):1331-8.
17. The Epidemiology of Dry Eye Disease: Report
of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). The Ocular
Surface. April 2007;5(2):93-107.
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SPECIAL CARE
Keeps Specialty
Lens Wearers
Contact lens care is a vital
step to the continued safety
and health of the contact lens
patient. So how does lens care
differ in the case of sclerals
and other specialty lenses?
Safe
By Susan J. Gromacki, OD, MS
W
SCLERAL CONTACT LENSES
Currently, scleral gas permeable
(GP) contact lenses represent the
fastest growing segment of the
specialty contact lens industry.1
Already invaluable for treating
patients with keratoconus and
other corneal irregularities, scleral
lenses are now also being worn
by healthy patients who require
simple refractive correction.
Inherently larger than corneal
GP lenses, sclerals are designed to
vault the cornea and rest on the
sclera. As such, they must be filled
with solution prior to application
to prevent air bubbles from forming underneath the lens (Figure 1),
which can compromise comfort,
vision and corneal health (i.e.,
compression of the epithelium
20
Photo: Greg DeNaeyer, OD
e and our
patients are
fortunate
to live in an
age where
we have a variety of contact lens
options designed to improve
vision and comfort, and promote
ocular surface health. These
specialty lenses are truly different
and, as such, require special care.
Fig. 1. Scleral contact lens with insertion bubble.
and differential oxygen levels). In
order to prevent this solution from
spilling during application, patients
should be instructed to keep their
head down, parallel to the ground.
In this position, the patient should
open both eyelids wide (scleral
lenses average about 16.0mm in
diameter), gently place the lens on
the conjunctiva and then close the
eyelids.2
ABOUT THE AUTHOR
Dr. Gromacki is a Fellow of
the American Academy of
Optometry and a Diplomate
in the Cornea, Contact Lens,
and Refractive Technologies
section. She has written
extensively and lectured
internationally on the topics of cornea and
contact lenses and serves as the Director of the
Contact Lens Service at a subspecialty group
practice in Maryland.
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Note a scleral lens’s thickness
(approximately 0.3mm), diameter
and depth can affect its center of
gravity, making it more difficult to
balance the lens on one finger compared with a soft or corneal GP
lens. As such, a number of methods
may be utilized to assist in holding
the lens for proper insertion:
• The “tripod method.” After
forming a tripod with the thumb,
index finger and middle finger, rest
the lens in the center of the three
digits for application.
• A large DMV or suction cup.
As a recommendation, cut a small
slice off the bottom or order the
suction cup fenestrated so that it
will be easier to remove from the
lens following placement on the
ocular surface.
• A #8 O-ring. Available from
GP lens manufacturers or at many
hardware stores. Before application, place the ring on the tip of the
index finger and place the lens on
top of the ring.3
• Ezi Scleral Lens Applicator (QCase). A ring-like device equipped
with a bowl on which to balance
the scleral lens during application.
• See Green Lens Inserter
(Dalsey Adaptives). A device
equipped with a permanent standing suction cup and green light to
help focus the patient’s gaze during
application (Figure 2). According
to the manufacturer, the device is
particularly suited for patients who
struggle with manual dexterity, are
monocular and cannot see the lens,
or need to hold their eyelids.4
FILLING THE LENS
Scleral lenses provide minimal tear
exchange, meaning the solution
placed in the bowl of the lens prior
to application remains in direct
contact with the cornea during
most of the lens-wearing day; thus,
it is critical to use a nonpreserved
solution to prevent preservatives
from inducing allergic or hypersensitivity reactions.5,6
Scleral lenses are commonly
filled with unit-dose sodium chloride 0.9% inhalation/irrigation
solution, which can be obtained in
3mm or 5mm vials from a pharmacy or online. Note that although
it is a non-prescription item, some
pharmacies may still require a prescription. I provide a preprinted,
signed medical prescription to all
of my scleral lens patients. This has
two benefits: it tells the pharmacist that the solution is for scleral
contact lenses (thus saving us both
a phone call) and it increases the
likelihood that the patient’s medical insurance will cover
the expense.5,6
Scleral patients suffering from dry eye
and those whose lenses
exhibit areas of touch
or minimal clearance
may benefit from filling their lenses with
unit-dose artificial tears
instead, which provide
extra lubrication and
corneal protection.
Keep in mind, however, that only the clear
Fig. 2. The See Green Lens Inserter with stand
(Dalsey Adaptives).
brands, not the milky
Enzymatic Cleaners
Patients wearing GP, soft or
hybrid lenses who are prone
to heavy protein deposition
can use an enzymatic cleaner
once per week or more.
or viscous ones, will work without
compromising visual clarity. Also,
try to avoid formulations with HPGUAR; while a fantastic wetting
agent, it has the potential to gel
underneath the lens.7
Manufacturers are also increasingly recommending against use
of larger (e.g., 4 oz.) bottles of nonpreserved saline because they often
contain buffers, which can contribute to debris or mucin buildup
underneath the lens.8,9 Patients
are also less likely to comply with
discarding a larger bottle should it
become contaminated.
Note that all of the options currently available for filling scleral
lenses are considered off-label by
the US Food and Drug Administration. That being said, research may
one day produce a solution that is
more biocompatible and similar to
the tear film, but for now, unitdose nonpreserved saline is the best
option we have at this time.5,6
CLEANING SCLERAL LENSES
Scleral contact lenses are simply
large GP lenses, so any solutions
approved to clean and disinfect
corneal GP lenses can be used for
scleral lenses. However, because
there is less tear flow under the
edge of a scleral lens compared
with a corneal GP lens, additional
care should be taken to ensure that
the lens surface is both clean and
free of pathogens. I recommend
a separate daily cleaner for all
scleral lenses, regardless of whether
they’re plasma-treated or not.
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SPECIAL CARE KEEPS SPECIALTY LENS WEARERS SAFE
Examples of daily cleaners suitable for GP lenses include: Boston
Cleaner (Bausch + Lomb), Boston
Advance Cleaner (Bausch + Lomb),
Optifree Daily Cleaner (Alcon),
or Optimum by Lobob ‘Extra
Strength Cleaner’ (Lobob). The latter, or an isopropyl alcohol-based
cleaner approved for GP lenses,
may be preferable for cleaning high
Dk materials, which may scratch
more easily with more abrasive
cleaners. I also follow the FDA’s
recommendation to rinse with
saline, rather than tap water, to remove all cleaner from the lens, due
to the fact that all water contains
some levels of bacteria, fungi and
amoebae.11
Lens disinfection should be
performed with a GP conditioning/disinfection solution such as
Boston Advance Comfort Formula
Conditioning Solution (Bausch +
Lomb) or Boston Conditioning
Solution (Bausch + Lomb) or with
Generic Solutions, Specific Problems
According to a recent study, the main determinant (38%) of which
type of contact lenses were fitted and purchased was price.14 If lens
price has such an effect on the final selection when the doctor is
the primary decision-maker, imagine its considerable impact when
patients are making purchasing decisions on their own, such as
when selecting a solution.
Every year or so, a retailer entertains bids on which company will
produce and package its private-label solution. When the contract
expires, the formulation may likely change. Because a retailer
generally accepts the lowest bidder, companies typically do not
place their premium solutions in generic bottles. So, because
expiration dates are typically 18 to 36 months into the future, there
could be two different chemical formulations residing in two of
the same bottles sitting side-by-side on the store shelf. Likewise, a
retailer can label two bottles of the same formulation differently—
each to mimic popular brands.15,16
The bottom line: older formulations were the state-of-the art 10
or 15 years ago, and most work well for most patients. But since
then, we have learned more about material/solution interaction;
the private label solution may not be what’s most compatible
for the patient.17,18 Research has also demonstrated a statistically
higher rate of such ocular complications with patients who use
private label compared with name-brand solutions.19
Additionally, FDA recommended in 2010 that all multipurpose
solutions carry “rub and rinse” instructions, and the care systems
launched since then have complied. However, some mass retailers’ packages still contain the words “no rub.” It has been common
knowledge for several years that a cleaner lens is a healthier lens,
and research has proven that digitally rubbing a lens is more effective than not at removing the deposits that can lead to inflammation or infection.20
We have made great advances in solutions over the past few
years—including improved cleaning and disinfection, less toxicity,
and increased comfort and wettability—and the patient who buys
generic isn't benefiting from that technology.16
22
a GP multipurpose solution such as
Boston Simplus Multi-Action Solution (Bausch + Lomb), Menicon
Unique pH (Menicon), Optifree
GP (Alcon), or Optimum C/D/S
(Lobob). In addition, the Menicon
Deluxe Care System (with Progent)
is now approved for home use.
Many scleral lens fitters advise
sensitive patients to rinse the lens
with nonpreserved saline prior to
application. While this removes
any residual solution—including
its preservatives—left over from
the disinfection process, it can also
diminish wettability. Hydrogen
peroxide solutions like PeroxiClear
(Bausch + Lomb) or Clear Care
(Alcon) are good preservativefree alternatives; however, these
solutions are FDA-approved for
GP lenses only if they are digitally
rubbed prior to disinfection. If
necessary, larger cases that accommodate diameters up to 30mm can
be obtained from online stores like
the Dry Eye Shop. The catalytic
neutralization disc is not included
with purchase, however, so one
needs to be transferred from the
smaller case prior to use.12
HYBRID LENSES
Hybrid contact lenses are comprised of a GP center surrounded
by a hydrophilic skirt. Examples
include the Duette and UltraHealth (SynergEyes). Manufacturer
guidelines advise patients who
wear these lenses to digitally rub
the lens, front and back, with a
daily cleaner approved for silicone
hydrogel soft lenses, then rinse off
the cleaner with nonpreserved saline. For disinfection, manufacturer
guidelines recommend Clear Care
(Alcon), BioTrue (Bausch + Lomb),
Renu fresh (Bausch + Lomb) or
Complete Easy Rub (Abbott Medical Optics). It should be noted that
UltraHealth, due to its vaulted
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
020_RCCL0415_F3.indd 22
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Fig. 3. Acceptable NovaKone (Alden Optical) fit on a keratoconic eye,
enhanced with high molecular weight fluorescein.
design, needs to be filled with nonpreserved saline or artificial tears
prior to insertion, then inserted
with the head kept down similar to
inserting a scleral lens.
For keratoconus patients who
wear the KC and ClearKone
(SynergEyes) hybrid lenses, preservative-based care systems should
be avoided. Hybrid lens manufacturer guidelines recommend Clear
Care or Oxysept Ultracare (Abbott
Medical Optics).
For all hybrid lenses, a digital
rubbing step is required, as they
have a six-month replacement
schedule. Since they contain a soft
skirt, gas permeable solutions are
contraindicated.
SOFT LENSES FOR
KERATOCONUS
There are now excellent soft contact lens designs used specifically
to treat keratoconus. Because these
lenses are custom-produced and
last up to three months, a digital
rubbing step is typically recommended. (Of specific note, Bausch
+ Lomb recommends rubbing its
KeraSoft IC lens in between the
fingers, rather than in the palm of
the hand.13)
Because soft lenses for keratoconus tend to be thicker than
disposable soft contact lenses, most
manufacturers recommend using
nonpreserved disinfectants because
of the potential for absorption
into the lens matrix. Alden Optical
recommends hydrogen peroxide
systems for its NovaKone lens
(Figure 3), while Bausch + Lomb
recommends use of either multipurpose or hydrogen peroxide
with its KeraSoft IC. However, if
multipurpose solution is used, B+L
suggests rinsing it off with sterile
rinsing solution prior to application.13
CONCLUSION
The fitting of scleral and other
specialty contact lenses requires
great diligence and attention to detail on the part of the practitioner.
However, even the best scleral lens
fit can be compromised by poor
lens care on the part of the patient.
This part of the equation is just as
critical to contact lens success.
For further information on contact lens care, please consult each
lens and/or material manufacturer
for its specific care recommendations.
RCCL
1. Nichols, J. 2014 annual report: Contact lenses
2014. Contact Lens Spectrum. 2015;30(1):2227.
2. Gromacki SJ. Handling and care of scleral
GP contact lenses, Part 1. Contact Lens Spectrum. 2011;27(10):27.
3. Gromacki SJ. Scleral GP contact lens insertion, removal, and care. [Webinar.] Gas Permeable Lens Institute, March 2014. Available at:
www.gpli.info/videos/webinar-2014-03.htm.
4. Dalsey Adaptives. The See-Green Lens Inserter. Available at: www.dalseyadaptives.com.
Accessed February 2015.
5. Gromacki SJ. Handling and care of scleral
GP contact lenses, Part 2. Contact Lens Spectrum. 2012;27(1):19.
6. Gromacki SJ. Scleral GP lens preparation:
The latest standard of care. Contact Lens
Spectrum. 2013;28(11):25.
7. Smythe M. Personal communication, April
10, 2014.
8. Imavasu M, Hori Y, Cavanagh HD. Effects of
multipurpose contact lens care solutions and
their ingredients on membrane-associated
mucins of human corneal epithelial cells. Eye
Contact Lens. 2010 Nov;36(3):361-6.
9. Gorbet MB, Tanti NC, Jones L, Sheardown
H. Corneal epithelial cell biocompatibility to
silicone hydrogel and conventional hydrogel
contact lens packing solutions. Mol Vis 2010
Feb 19;16:272-82.
10. US Food and Drug Administration. Medical
Devices. Available at: www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/
HomeHealthandConsumer/ConsumerProducts/
ContactLenses/. Accessed February 2015.
11. Ward M. General Session #9: Contact Lens
Care. Lecture at The Global Specialty Lens
Symposium, January 24, 2015; Las Vegas,
Nevada.
12. The Dry Eye Shop. Lens Cases. Available
at: www.dryeyeshop.com/lens-cases-c95.aspx.
Accessed February 2015.
13. A&R Optical. Patient Instruction/Wearer’s
Guide for Intelliwave3/KeraSoft IC. Available
at: www.artoptical.com/files/documents/
resources/Intelliwave_Patient_Instruction_-_
Efrofilcon_A_1.pdf. Accessed February 2015.
14. Ichijima H, Shimamoto S, Ariwaka Y, et al.
Compliance study of contact lens wearing in
Japan, part 1: Internet survey of actual circumstances of lens use. Eye & CL 2014;40(3):169174.
15. Ferris State University. Private Label Lens
Care Guide. Available at: www.ferris.edu/
HTMLS/colleges/michopt/vision-researchinstitute/PDFs/contact-lens-solutions.pdf.
Accessed February 2015.
16. Gromacki SJ. The truth about generics.
Contact Lens Spectrum. 2005;20(12):24.
17. Green JA, Phillips KS, Hitchins VM, et al.
Material Properties That Predict Preservative
Uptake for Silicone Hydrogel Contact Lenses.
Eye Contact Lens. 2012 Nov;38(6):350-357.
18. Andrasko G, Ryen K. Corneal staining and
comfort observed with traditional and silicone
hydrogel lenses with multipurpose solution
combinations. Optom. 2008; 79: 444-454.
19. Forister JY, Forister EF, Yeung KK, et al.
Prevalence of contact lens-related complications: UCLA contact lens study. Eye Contact
Lens. 2009;35(4):174-80.
20. Schnider C: Clinical performance and effect
of care regimen on surface deposition of galyfilcon A contact lenses. [Electronic abstract
055102.] Optom Vis Sci. 2005; 82.
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
020_RCCL0415_F3.indd 23
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1 CE
Credit
(COPE Approval
Pending)
IS THAT CORNEAL
INFILTRATE STERILE
OR INFECTIOUS?
Differentiating between the two requires close observation and analysis.
Here’s a results-oriented approach.
By Jeffrey Sonsino, OD, and Shachar Tauber, MD
D
oes this sound familiar? “Doctor, I don’t
understand what’s
wrong. I have been
wearing my contact
lenses overnight for years and this
has never happened before.” Upon
close examination, you note the
presence of small, grayish aggregates in the corneal epithelium. The
diagnosis? Corneal infiltrates. But
how do you tell if they are sterile or
infectious—harmless, or a potential
serious problem?
As practitioners, we have seen
any number of contact lens-related
complications walk through our
doors. Corneal infiltrates and ulcers
are two such examples that have
long been an unfortunate reality of
patient care. In the 19th century,
treatment of corneal ulcers included
chemical cauterization with silver
nitrate. While we’ve come a long
way since those days in the care we
provide, when such adverse events
occur, differentiating infectious and
sterile infiltrates is still no easy task.
BREAKING IT DOWN
Corneal infiltrates result from the
penetration of white blood cells
into the corneal tissue as part of
the body’s inflammatory response
24
to the presence of bacterial toxins, enzymes and byproducts.1-4 A
corneal ulcer, by comparison, is an
epithelial defect with underlying
inflammation (which typically leads
to necrosis of corneal tissue).
Infiltrates and ulcers are similar
in that they both involve disruption
of the corneal epithelium; indeed, a
staining infiltrate may be the beginning of a corneal ulcer. The difference, however, is that while corneal
infiltrates are not sight-threatening,
corneal ulcers involve active tissue
damage caused either by infectious
or non-infectious etiologies. Infectious ulcers are caused by fungus,
virus, or parasites like Acanthamoeba) or, most commonly, bacteria.5
Alternately, noninfectious ulcers
result from autoimmunity, neurotrophic keratitis, allergy (e.g., shield
ulcers), inflammation from blepharitis or chemical burns, or idiopathic conditions (e.g., Mooren’s ulcer).
In the case of microbial insult,
the damage typically results in an
excavation of the corneal stroma,
which triggers an anterior chamber
response of flare with or without
cells (Figures 1, 2 and 3). For this
reason, the terms microbial keratitis
and bacterial ulcer are sometimes
used interchangeably.
Four subtypes of contact lensrelated corneal infiltrates exist:
microbial keratitis, contact lensinduced peripheral ulcer (CLPU),
contact lens-induced acute red eye
(CLARE) and infiltrative keratitis.
While the etiology of these subtypes
is multifactorial, research shows
significant overlap between their
clinical presentations, suggesting it
is not possible to clinically differentiate between them; rather, they
should be considered as stages of a
single disease spectrum.6
ABOUT THE AUTHORS
Dr. Sonsino is a partner in a
specialty contact lens and
anterior segment practice
in Nashville, Tenn. He is a
diplomate in the cornea,
contact lens, and refractive therapies section of
the AAO, a council member
of the cornea and contact lens section
of the AOA, a fellow of the Scleral Lens
Education Society and an advisory board
member of the GPLI. Dr. Sonsino is boardcertified by the ABO.
Dr. Tauber is an ophthalmologist at Mercy Clinic Eye
Specialists and Surgery
Center. He is a fellow of
the American Academy
of Ophthalmology and a
member of the American
Society of Cataract and Refractive Surgery and International Ocular
Surface Society.
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Fig. 1. Slit beam evaluation of a corneal ulcer. Deviation of the beam shows
corneal excavation.
THE “TWO CORNEAS”
When determining whether the corneal infiltrate is infectious or sterile,
one helpful method is to divide the
cornea into two distinct regions.
Consider that the central cornea
encompasses the 6mm of the
cornea apex whereas the peripheral
cornea is a 2mm to 4mm doughnut, with the limbus as its posterior
border.
Based upon the close approximation of the peripheral cornea to the
limbus (with its preponderance of
stem cells and vascularity), investigators believe the immune response
to be more active in this region
of the cornea. Quantification of
the nerve fibers shows a densely
innervated cornea and a five to six
times lower innervated peripheral
cornea.7 Higher mitotic activity
has also been demonstrated in the
peripheral cornea.8
These observations indicate the
two distinct regions of the cornea
have key anatomic, physiologic and
pathologic differences, allowing for
the generalization that infiltrates
in the periphery of the cornea are
non-infectious while infiltrates in
the central 6mm of the cornea may
have an infectious etiology.9
ALWAYS TAKE NOTES
As with any medical concern that
presents to the clinic, careful history taking can lead the eye care
practitioner to identify the proper
diagnosis and resultant treatment
that gives the patient the best possible outcome with the least risk.
• Contact lenses. Contact lens
use is one identified risk factor for
the development of corneal infiltrates, as evidence shows continuous wear of contact lenses increases
the risk of ocular complications.
However, it is not the primary
cause of corneal infiltrates; rather,
it is simply one of several contributors. Other risk factors for corneal
infiltrate development in continuous wear contact lens patients
include age (i.e., between 18 and
Release Date: April 2015
Expiration Date: April 1, 2018
Goal Statement: This course reviews the etiology, contributing factors and clinical presentations of sterile and infectious corneal
infiltrates. Key points in ocular examination
and treatment will also be discussed.
Faculty/Editorial Board:
Jeffrey Sonsino, OD, and Shachar Tauber, MD
Credit Statement: COPE approval for 1 hour
of continuing education credit is pending
for this course. Check with your state licensing board to see if this counts toward your
29 years) and a history of smoking,
corneal scarring, contact lens acute
red eye or corneal infiltrates.10
Of the different corneal infiltrate
types, microbial keratitis is the most
severe complication of contact lens
wear. In the 1980s and 1990s, risk
of microbial keratitis was found
to be four cases per 10,000 lens
wearers per year for daily wear and
20 cases per 10,000 wearers per
year for extended wear.11,12 Pseudomonas aeruginosa has been identified as the most common bacterial
source of microbial keratitis in
contact lens wearers.13
• Corneal trauma. Risk of microbial keratitis also increases any time
there is a history of corneal trauma
or foreign body presence due to the
possibility of incomplete removal.
This is especially true when the
foreign body is vegetative matter,
which is more likely to be contaminated by pathogens. Corneal
trauma may also include iatrogenic
etiologies, such as retained or broken sutures in penetrating keratoplasty patients.
• History of surgery. Because
anterior segment surgery compromises epithelial barrier function,
any corneal surgery carries a risk
of resultant infiltrative keratitis and
infectious ulcer. In particular, infiltrative keratitis is associated with
astigmatic keratectomy, penetrating
keratoplasty, DSAEK, pterygium
removal, trabeculectomy, LASIK
CE requirements for relicensure.
Joint-Sponsorship Statement: This continuing education course is joint-sponsored
by the Pennsylvania College of Optometry.
Disclosure Statement: Dr. Sonsino consults for SynergEyes, Bausch + Lomb,
Alcon, Visionary Optics and Optovue, has
received grant support from Visioneering,
and owns stock in LVR Technology.
Dr. Tauber consults for AMO and Allergan,
has received grant support from the
Department of Defense, and owns stock in
Calhoun Vision and Ocugenics.
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IS THAT CORNEAL INFILTRATE STERILE OR INFECTIOUS?
Fig. 2. Sodium fluorescein evaluation of a corneal ulcer. The hyperfluorescence
is attributed to staining of the mucous plug.
and cataract surgery.14-17 It is not
clear if the relative risk is greater
with regards to a particular corneal
surgery.
• Ocular surface disease. Sterile
peripheral (i.e., marginal) corneal
infiltrates may result from a compromised ocular surface. Staphlococcal blooms in the lids spill bacterial byproducts onto the cornea,
which triggers a hypersensitivity
reaction that is theorized to lead
to infiltrates.18,19 Often small and
multiple in nature, these infiltrates
are typically positioned roughly
1mm from the limbus. Marginal
infiltrates may be asymptomatic, or
may be accompanied by conjunctival injection. Pathogenesis includes
bacterial, allergic or autoimmune
etiologies.
In the case of severe blepharitis
and meibomian gland dysfunction
(MGD), the bacterial blooms within
the meibomian glands can produce
a hypersensitivity reaction, leading
to peripheral, non-staining subepithelial infiltrates (SEIs). The body
responds to the to antigen presented
by this presence of Staphlococcal
bacteria in the lids by recruiting
white blood cells to the area as part
of an antibody response. For this
reason, the SEIs associated with
26
Staphlococcal marginal keratitis are
typically in the 2 o’clock and 10
o’clock regions and the 4 o’clock
and 8 o’clock regions, contiguous
with the upper and lower lids.
Similarly, ocular rosacea can
lead to MGD. However, with
severe rosacea, potential outcomes
include marginal infiltrates, chronic
conjunctivitis, sterile ulceration,
corneal neovascularization and
corneal scarring (Figures 4 and 5).
It is also critical to rule out herpes
simplex keratitis (HSK), which
may resemble the infiltrates seen in
Staphlococcal marginal keratitis.
HSK lesions, however, are typically
harder to treat and appear with
deeper stromal inflammation.20
• Allergic conjunctivitis. All
eye care practitioners are familiar
with the signs and symptoms of
Fig. 3. Contact lens-related microbial
keratitis. Ulcer filled with mucous
plug.
seasonal allergic conjunctivitis,
atopic conjunctivitis and papillary
conjunctivitis. Perhaps less commonly encountered, however, is
a variant of allergic conjunctivitis
found most often in young boys.
Vernal conjunctivitis is a severe
bilateral condition characterized
by photophobia, chemosis, sticky
discharge, eosinophils at the limbus
(i.e., Horner-Trantas dots) and
shield ulcers.21 Secondary bacterial
keratitis typically results from 10%
of shield ulcers.22
• Medications. Contamination
of ocular medications has been
implicated in numerous case studies
of corneal ulceration; the pathogen
may originate in topical medication
dropper tips or within the medications themselves.23,24
LOOK FOR THE SIGNS
The next step after collecting a
complete patient history is to conduct an ocular examination, which
can help determine whether an
infiltrate is sterile or infectious. The
following are all key elements of a
physical examination that can help
with proper diagnosis:
• Does the patient report symptoms of pain, photophobia or loss
of vision? What about corneal sensation? Pain out of proportion with
the signs points to Acanthamoeba,
while loss of corneal sensation (i.e.,
lack of pain upon history or with
the corneal wisp test) signals HSK.
• Do you observe blepharitis,
nasolacrimal duct obstruction,
poor or incomplete blink or lagophthalmos, entropion/ectropion
or conjunctival injection? Is the
conjunctival injection localized or
diffuse? How about circumlimbal?
Be sure to grade the injection (i.e.,
1-4+). What about corneal foreign
bodies?
• Is there discharge and, if so,
what are its characteristics?
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Fig. 4. Severe ocular rosacea. Visible on the lid is tyalosis, scalloped lid
margin and telangiectasia, which signals severe inflammation within the
meibomian glands.
• What is the location, depth and
size of the infiltrate(s)? Do you observe stromal loss?
• Is there visible loss of corneal
endothelium? What about plaque
or pigment on the endothelium?
• What is the status of the patient’s
corneal graft, if they have one?
• Do you observe any stromal
haze and edema?
• Do you observe anterior chamber reaction, cells/flare or hypopyon?
• Are there vitreous cells present?
Note, a corneal ulcer will rarely
lead to endophthalmitis with vitreous cells present.
THE CULTURAL REVOLUTION
In the last 20 years, a major shift
in thought regarding the need to
obtain corneal material to identify
offending organisms and determine sensitivity to antibiotics has
occurred. Today, broad-spectrum
fluoroquinolones are readily available as the primary treatment for
a corneal infiltrate believed to be
infectious. Thus, the majority of
community-acquired cases of bacterial keratitis are typically resolved
with empiric therapy and managed
without smears or cultures.
However, such tests are indicated
in certain cases, including those that
involve a corneal infiltrate that is
central, large and extends to the mid
to deep stroma, particularly with
significant thinning of the cornea or
scleral extension; those chronic in
nature or unresponsive to broadspectrum antibiotics; and those that
present with atypical clinical features suggestive of fungal, amoebic
or mycobacterial keratitis.25 Smears
and cultures may also be helpful
in cases with an unusual history,
such as trauma caused by vegetable
matter or if the patient wore contact
lenses while in a hot tub.25
Additional specialized studies can
help identify atypical organisms, for
example in sight-threatening or severe keratitis of suspected microbial
origin.25 However, the American
Academy of Ophthalmology—noting that the hypopyon that occurs
in eyes with bacterial keratitis is
usually sterile—recommends aqueous or vitreous taps should not be
performed unless there is a high
suspicion of microbial endophthalmitis, such as following an intraocular surgery, perforating trauma
or sepsis.25
When obtaining corneal material, proper technique is critical
to identify the causative organism
and select the proper antibiotic,
antiviral, antifungal or antiprotozoal medications. The process of
obtaining corneal material should
first involve the instillation of a
topical anesthetic agent (note that
tetracaine should be avoided due to
its antimicrobial effect) followed by
the use of a heat-sterilized platinum
spatula, blade, jeweler’s forceps
or other similar sterile instrument
to obtain scrapings of material
from the advancing borders of the
infected area of the cornea. Culture
yield may be improved by avoiding
anesthetics with preservatives.
A thiol or thioglycollate brothmoistened dacron/calcium alginate
or sterile cotton swab can also be
used to obtain material.25 However,
solid as well as liquid plating media
is always recommended.26 If treatment is refractory and cultures do
not yield results, it is advisable to
halt antibiotics in order to isolate
the exact pathogen for further
treatment. It is also important to
consider culturing contact lenses,
contact lens cases and contact lens
solutions if appropriate and available.
TREATMENT OPTIONS
Topical antibiotics are the first-line
therapy for suspected or cultureproven bacterial keratitis; however,
the selection depends on severity. A
peripheral infiltrate associated with
lid margin disease may be appropriately managed with inexpensive
early fluoroquinolones such as
ofloxacin, ciprofloxacin, azithromycin or a polymixin-bacitracin
ointment, while central or more
aggressive infiltrates warrant use of
fourth-generation fluoroquinolones
such as gatifloxacin, moxifloxacin
or levofloxacin.
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IS THAT CORNEAL INFILTRATE STERILE OR INFECTIOUS?
Fig. 5. Corneal scarring with severe
ocular rosacea.
For more serious keratitis, the use
of besifloxacin has recently been
advocated. This new fluoroquinolone has high MIC values for many
common ophthalmic pathogens
and a unique compound containing
polycarbophil, edetate disodium
dihydrate and sodium chloride,
which allows for greater ocular
surface contact time. Additionally,
its position as the only ophthalmic
fluoroquinolone not used systemically makes it unique by reducing
the risk of antibiotic resistance.
In severe situations with risk for
perforation, failure to respond to
monotherapy or central aggressive
ulcers with the potential for vision
loss, the use of combination fortified-antibiotic therapy should be
considered. This should be formulated by a compounding pharmacy
that is a member of the Pharmacy
Compounding Accreditation Board.
Note that methicillin-resistant
Staphylococcus aureus (MRSA)
has been isolated with increasing
frequency from patients with bacterial keratitis. Fluoroquinolones are
generally poorly effective against
MRSA ocular isolates; however,
vancomycin has demonstrated some
success.27 In cases of severe ulcer,
consider more complete coverage
with combination therapy.28
Systemic antibiotics are rarely
needed, but may be considered in
severe cases where the infectious
process has moved to adjacent tissues (e.g., the sclera) or when there
28
is impending or frank perforation
of the cornea. Research shows oral
tetracycline controls the anticollagenase activity commonly seen
in necrotizing infections such as
Pseudomonas.29 Systemic therapy
is necessary in gonococcal keratitis
because of the extremely aggressive
nature of this organism (corneal
penetration in 24 hours with inadequate treatment). For this reason,
the CDC recommends immediate
hospitalization with IV antibiotics
for adult gonococcal infection.
Treating viral, fungal and amoebic keratitis may be challenging and
is beyond the scope of this article.
Regardless, the eye care provider
who has clinical suspicion or laboratory data supporting any of these
infectious processes should be fluent
in their current treatment options
or have available the appropriate
consultants to offer prompt referral.
Determining whether an infiltrate
is sterile or infectious is not an easy
task for even the best clinicians.
However, with careful history taking, physical examination, differential diagnosis and proper treatment,
patients have the best chance of
making the best of a bad situation.
RCCL
1. Josephson JE, Caffery BE. Infiltrative keratitis
in hydrogel lens wearers. Int Contact Lens Clin.
1979;6:223–41.
2. Szczotka-Flynn L, Lass JH, Sethi A, et al. Risk
factors for corneal infiltrative events during continuous wear of silicone hydrogel contact lenses.
Invest Ophthalmol Vis Sci. 2010 Nov;51(11):5421-30.
3. Pearlman E, Johnson A, Adhikary G, et al.
Toll-like receptors at the ocular surface. Ocul Surf.
2008;6:108–16.
4. Sweeney DF, Naduvilath TJ. Are inflammatory
events a marker for an increased risk of microbial
keratitis? Eye Contact Lens. 2007 Nov;33(6 Pt
2):383-7; discussion 399-400.
5. Online Merck Manual. Corneal Ulcer. Available
at: www.merckmanuals.com/professional/eye_
disorders/corneal_disorders/corneal_ulcer.html.
Accessed March 10, 2015.
6. Efron N, Morgan PB. Can subtypes of contact
lens-associated corneal infiltrative events be clinically differentiated? Cornea. 2006 Jun;25(5):540-4.
7. Müller, Vrensen, Pels, et al. Architecture of Human Corneal Nerves. Invest Ophthalmol Vis Sci.
April 1997;38(5):985-94.
8. Lemp MA, Mathers WD. Corneal Epithelial Cell
Movement in Humans. Eye. 1989;3:438-45.
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9. Mah FS. Corneal infiltrates merit care: Differentiating sterile and infectious conditions key to
diagnosis, treatment. Ophthalmology Times. 2010
Oct;35(19):42.
10. McNally JJ, Chalmers RL, McKenney CD,
Robirds S. Risk factors for corneal infiltrative
events with 30-night continuous wear of silicone
hydrogel lenses. Eye Contact Lens. 2003 Jan;29(1
Suppl):S153-6; discussion S166, S192-4.
11. Poggio EC, Glynn RJ, Schein OD, et al. The
incidence of ulcerative keratitis among users
of daily-wear and extended-wear soft contact
lenses. N Engl J Med. 1989;321:779–83.
12. Cheng KH, Leung SL, et al. Incidence of
contact-lens-associated microbial keratitis and its
related morbidity. Lancet. 1999;354:181–5.
13. Mondino BJ, Weissman BA, Farb MD, et al.
Corneal ulcers associated with daily-wear and
extended-wear contact lenses. Am J Ophthalmol.
1986;102:58–65.
14. Adrean SD, Cochrane R, Reilly CD, Mannis MJ.
Infectious keratitis after astigmatic keratotomy in
penetrating keratoplasty: review of three cases.
Cornea. 2005 Jul;24(5):626-8.
15. Moon SW, Kim YH, Lee SC, Lee MA, Jin KH. Bilateral peripheral infiltrative keratitis after LASIK.
Korean J Ophthalmol. 2007 Sep;21(3):172-4.
16. Villarrubia A, Cano-Ortiz A. Candida keratitis
after Descemet stripping with automated endothelial keratoplasty. Eur J Ophthalmol. 2014
Nov-Dec;24(6):964-7.
17. Akpek EK, Demetriades AM, Gottsch JD.
Peripheral ulcerative keratitis after clear corneal
cataract extraction(1). J Cataract Refract Surg.
2000 Sep;26(9):1424-7.
18. Mondino BJ. Inflammatory diseases of the
peripheral cornea. Ophthalmol 1998;95:463-12.
19. Mondino BJ, Lahedi AK, Adamu SA. Ocular
immunity to Staphylococcus aureus. Invest Ophthalmol Vis Sci 1987;28:560.
20. One Network. Herpes Simplex Virus.
Available at: one.aao.org/focalpointssnippetdetail.aspx?id=356f0d13-8853-410f-ac6b7ff5e0257800. Accessed March 25, 2015.
21. Bonini S, Coassin M, Aronni S, Lambiase A.
Vernal keratoconjunctivitis. Eye. 2004;18:345–51.
22. Reddy JC, Basu S, Saboo US, et al. Management, clinical outcomes, and complications of
shield ulcers in vernal keratoconjunctivitis. Am J
Ophthalmol. 2013 Mar;155(3):550-9.
23. Donzis PB. Corneal ulcer associated with
contamination of aerosol saline spray tip. Am J
Ophthalmol. 1997 Sep;124(3):394-5.
24. Schein OD, Wasson PJ, et al. Microbial keratitis
associated with contaminated ocular medications. Am J Ophthalmol. 1988 Apr 15;105(4):361-5.
25. American Academy of Ophthalmology
Cornea/External Disease Panel. Bacterial keratitis.
Limited revision. San Francisco (CA): American
Academy of Ophthalmology (AAO); 2011.
26. Bhadange Y, Sharma S, Das S, Sahu SK. Role
of liquid culture media in the laboratory diagnosis
of microbial keratitis. Am J Ophthalmol. 2013
Oct;156(4):745-51
27. Eiferman RA, O'Neill KP, Morrison NA. Methicillin-resistant Staphylococcus aureus corneal
ulcers. Ann Ophthalmol. 1991 Nov;23(11):414-5.)
28. Asbell PA, Colby KA, Deng S, et al. Ocular
TRUST: nationwide antimicrobial susceptibility
patterns in ocular isolates. Am J Ophthalmol
2008;145:951-8.
29. Ralph RA. Tetracyclines and the treatment
of corneal stromal ulceration: a review. Cornea.
2000 May;19(3):274-7.
REVIEW OF CORNEA & CONTACT LENSES | JANUARY 2015
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3/27/15 4:02 PM
CE TEST ~ APRIL 2015
EXAMINATION ANSWER SHEET
Is That Corneal Infiltrate Sterile or Infectious?
1.
a.
b.
c.
d.
All of the following are likely symptoms or signs of corneal infection EXCEPT:
Pain and photophobia.
Discharge and foreign body sensation.
Anterior chamber reaction that includes cell and flare.
Lack of debris at the tear menuscus.
2. There are many reasons to culture corneal ulcers. Which of the following
is NOT one of them?
a. Culturing would be a helpful medico-legal component of your record in case
the ulcer doesn’t respond to empiric treatment.
b. Culturing reveals sensitivities of the organism(s).
c. Because no single agent is generally effective for all infections.
d. Because ineffectively treated organisms are difficult to isolate.
3. Currently, the most effective/complete treatment plan for resistant
bacterial infection is:
a. Vancomycin and ceftazidime.
b. Tobramycin.
c. Gentamycin and Ocuflox.
d. Ocuflox and erythromycin.
4. Which of the following statements is true regarding corneal infiltrates?
a. Sterile infiltrates are often single in number and are found closer to the visual
axis.
b. Corneal infiltrates at least histologically present in all infections.
c. Large, central infiltrates with overlying stains are probably sterile.
d. Corneal infiltrates associated with microbial keratitis generally produce little
to no pain and photophobia.
5.
a.
b.
c.
d.
The most common cause of perennial allergic conjunctivitis is:
Ragweed or tree pollen.
Summer grasses.
Home allergens, such as dust mites and animal dander.
Multipurpose disinfecting solutions used in contact lens care.
6. Which of the following is not true regarding the use of systemic
antibiotics?
a. They often provide a more effective dose to the cornea than topicals alone.
b. They have a lower chance of producing an allergic response.
c. They are often ineffective when the infection has scleral extension.
d. Tetracycline may aid in patients with an impending corneal melt.
7.
a.
b.
c.
d.
Risk for infiltrative keratitis is increased with all of the following EXCEPT:
Poor compliance/hygiene.
Smoking.
History of corneal scarring and CLARE.
Age 39 to 40.
Valid for credit through April 1, 2018
Online: This exam can also be taken online at www.reviewofcontactlenses.com.
Upon passing the exam, you can view your results immediately. You can also
view your test history at any time from the website.
Directions: Select one answer for each question in the exam and completely
darken the appropriate circle. A minimum score of 70% is required to earn credit.
Mail to: Jobson Optometric CE, Canal Street Station, PO Box 488 New York, NY 10013
Payment: Remit $20 with this exam. Make check payable to Jobson Medical
Information LLC.
Credit: COPE approval for 1 hour of CE credit is pending for this course.
Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry
Processing: There is an eight-to-10 week processing time for this exam.
Answers to CE exam:
A
B
C
1.
A
B
C
2.
A
B
C
3.
A
B
C
4.
A
B
C
5.
6.
7.
8.
9.
10.
D
D
D
D
D
A
B
C
D
A
B
C
D
A
B
C
D
A
B
C
D
A
B
C
D
Evaluation questions (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor)
Rate the effectiveness of how well the activity:
1
2
3
4
5
11. Met the goal statement:
12. Related to your practice needs:
1
2
3
4
5
13. Will help improve patient care:
1
2
3
4
5
1
2
3
4
5
14. Avoided commercial bias/influence:
15. How do you rate the overall quality of the material? 1
2
3
4
5
16. Your knowledge of the subject increased: Greatly
Somewhat
Little
17. The difficulty of the course was:
Complex
Appropriate Basic
18. How long did it take to complete this course? _________________________
19. Comments on this course: _________________________________________
___________________________________________________________________
20. Suggested topics for future CE articles: ______________________________
___________________________________________________________________
Identifying information (please print clearly):
First Name
Last Name
Email
8. The incidence rate for microbial keratitis has been estimated to range from
what to what per 10,000 extended-wear lens patients per year:
a. 18 to 20.
b. 4 to 5.
c. 34 to 38.
d. 1 to 2.
The following is your:
Home Address
Business Address
Business Name
Address
City
9. Which of the following is NOT a risk for microbial keratitis?
a. Wearing contact lenses overnight.
b. History of corneal trauma or foreign body.
c. Prior corneal surgery.
d. Daily use of aspirin.
10. Which of the following is true regarding monotherapy use in presumed
microbial keratitis?
a. A fourth-generation fluoroquinolone is probably the best overall option and
can be used alone for deep central ulcers.
b. Besivance is likely the best option for MRSA infections.
c. Monotherapy should be reserved for use in central infiltrates only.
d. Erythromycin is generally the best treatment option pending culture results.
State
ZIP
Telephone #
-
-
Fax #
-
-
By submitting this answer sheet, I certify that I have read the lesson in its entirety
and completed the self-assessment exam personally based on the material presented. I have not obtained the answers to this exam by fraudulent or improper means.
Signature: ________________________________________ Date: _____________
Please retain a copy for your records.
LESSON 111206, RO-RCCL-0415
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3/27/15 4:02 PM
The GP Expert
By Stephanie L. Woo, OD
Troubleshooting GP Complications
Many GP lens problems are easily resolved once identified.
C
ontact lenses, whether
rigid or soft, are a
foreign object on the
ocular surface. They
interact with the tear
film, cornea, bulbar conjunctiva
and palpebral conjunctiva; not surprisingly, complications may arise
on any of these ocular structures
as a result of contact. Additionally, the tear film is separated into
a pre- and post- contact lens film
with different thicknesses, which
can initiate a variety of issues.1
3 AND 9 O’CLOCK STAINING
A common complication with
corneal GP lenses is 3 and 9
o’clock staining, which is a result
of epithelial punctate staining of
the peripheral cornea near the edge
of the GP lens.2 These so-called
3 and 9 o’clock areas may not be
adequately resurfaced with tears
after a blink, thus resulting in
small desiccated regions. At first
the staining is mild, but over time
the epithelial defects may become
larger and denser. In severe cases,
those portions of the cornea may
become vascularized and even
form an opacity.
When treating, be sure to check
the edge of the contact lens first.
If you have a modification unit
within the office, you can alter
the edge of the lens to be rounded
or a “plus” shape to help with
edge-cornea interaction.3 If your
patient has a particularly high plus
or high minus lens, be sure to use
lenticular lens designs to improve
the edge of the lens.4
Inferiorly centered GP lenses are
another major cause of 3 and 9
30
dirt, dust or another small object
adheres to the ocular surface and
ends up underneath the lens—can
be an extremely frustrating issue
for both soft and GP lens wears
alike.
Even the smallest foreign body
can result in ocular surface damage, as with every blink, the
trapped object scratches the
delicate epithelium. This can lead
to track marks, which are both
very uncomfortable and potentially
painful for the patient (Figure 1).
Lens edge design plays a
major role regarding foreign
body entrapment; for example, if the edge is poorly finished or has unpolished secondary curves, this can lead
to more occurrences.5 Thus,
rolling the edge and polishing the secondary curves can
help reduce foreign body
entrapment. Be sure to also
check the edges for chipping,
as it can also increase risk of
foreign body entrapment.5 If
the problem persists, consider
switching to a larger diameter
Fig. 1. Foreign body entrapment under
lens, such as a scleral lens, to
GP lens shows track marks on the corneal
epithelium.
reduce or eliminate this issue.
3 and 9 o’clock staining, though
going larger is also an option. A
SPECTACLE BLUR
scleral lens will resolve the issue
Every once in a while, a patient
completely because of the fluid
comes in who complains that
layer between the cornea and the
when they remove their contacts
contact lens, which will act as a
and put on their glasses, their
lubricating cushion between the
vision is blurred. One reason this
lens and ocular surface. Switching
so-called spectacle blur may octhe patient to a hydrogel material
cur is from the accumulation of
may also be an answer.
fluid within the epithelial cells.
When contact lenses are removed,
FOREIGN BODIES
the swelling of these cells slowly
Foreign body tracking—when
decreases, and the spectacle blur
o’clock staining, so improving the
centration of the GP lens is key.3
Additionally, selecting a GP lens
material with good wettability
may help to decrease peripheral
erosion by reducing friction between the lens and ocular surface.
Artificial tears and gels can also
help increase lubrication, but will
need to be used consistently to
prevent further complications.
If all other modifications fail, try
altering the diameter of the lens.
Smaller diameters may decrease
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3/27/15 3:45 PM
what to expect usually eases patients
so they do not get
upset or anxious.
LENS
ADHESION
Lens adhesion is
the most common
complication of
extended wear GP
lenses.7,8 Upon examination, the lens
will be immobile
with mucous/lipid
deposits present
Fig. 2. Topography of a poorly fitting tangent streak
underneath. When
GP lens caused corneal steepening.
fluorescein is inusually resolves after an hour.6
stilled, none will be seen under the
Spectacle blur can also result
lens, indicating no tear exchange
from changes in corneal curvature
or lens movement. When the lens
that is not related to edema. This
is removed, an arcuate ring patis due to mechanical molding of
the cornea (resulting from lens
fit) or prolonged metabolic stress.
This issue is particularly common
in patients who wear flat-fitting or
hybrid lenses.
In the case of corneal molding, when the fit of the contact
lens is poor, the lens reshapes the
cornea, thus resulting in spectacle
blur (Figure 2). Spectacle blur is
Fig. 3. Corneal topography after
discontinuing GP lens wear for
usually not a large issue, unless
several months.
the primary cause is because the
tern is visible around the edge of
contact lens fit is inappropriate.
the lens.7 Patients usually do not
For example, in more extreme
have any complaints with lens
cases, deep stromal striae or
binding; in fact, they may report
opacification of the cornea can be
better comfort (except late in the
seen, which is indicative of further
day) because of the decreased lid
potential issues. In most cases,
however, the cornea will eventually interaction and movement.
If an extended wear patient exremold to a stable shape if the lens
is removed (Figure 3).6 Regardless, hibits lens adhesion, changing their
wearing schedule to daily wear
education on spectacle blur and
will likely resolve the issue. During
sleep, the pressure from the eyelids
squeezes out the tear layer under
the GP lens, which results in lens
binding.7 If lens binding occurs
with a daily wear patient, however,
the fit of the lens will need to be
altered. When the lens decenters,
the secondary and peripheral curve
junctions contact the flatter areas
of the cornea.7,8 This, combined
with pressure from the eyelids,
leads to lens adherence. Try altering the centration and curvature of
the lens to achieve a more centered
fit and check to make sure the
curves are well blended. If normal
modifications do not work, consider switching to an aspheric back
surface design.
Note that another potential
cause of lens adherence is dry eye,
specifically aqueous deficient dry
eye, so it is important to check
your patient for any type of dry
eye during their exam.
RCCL
1. Nichols J, King-Smith PE. Thickness of the
pre- and post-contact lens tear film measured
in vivo by interferometry. Invest Ophthalmol Vis
Sci. 2003 Jan;44(1):68-77.
2. Van der worp E, de Brabander J, Swarbrick
HA, Hendrikse F. Evaluation of signs and symptoms in 3 and 9 o’clock staining. Optom Vis Sci.
2009 Mar;86(3):260-5.
3. Holden T, Bahr K, Koers D, et al. The effect of secondary curve liftoff on peripheral
corneal desiccation. Am J Optom Physiol Opt
1987;64:113.
4. Henry VA, Bennett ES, Forrest JM. Clinical
investigation of the Paraperm EW rigid gas
permeable contact lens. Am J Optom & Physiol
Opt 1987;64:313-320.
5. Bennett, E. et al. Clinical Contact Lens Practice. Lippincott, Williams, and Wilkins. Philadelphia, PA. 2005. Pp 351.
6. Bailey SC. Contact lens complications. Optometry Today. June 4 1999.
7. Bennett, E. et al. Clinical Contact Lens Practice. Lippincott, Williams, and Wilkins. Philadelphia, PA. 2005. Pp 346-8.
8. Swarbrick HA, Holden BA. Rigid gas permeable lens binding: significance and lens factors.
Am J Optom Physiol Opt. 1987;64(11)815-823.
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3/27/15 3:45 PM
Corneal Consult
By James Thimons, OD
Managing Acute Corneal Hydrops
in Keratoconus
Using a structured approach to determine which factors impede healing will lead to
success with these often challenging scenarios.
C
32
inflammation and IOP-lowering
drugs. Some patients, however, may
require surgery if corneal edema
persists or resultant corneal scarring
affects visual clarity.
Conservative medical intervention
is usually sufficient to stave off the
more concerning consequences of
perforation, but overall has little impact on visual outcome or duration
of disease. Thus, doctors are turning
to other, more advanced methods of
disease management. Recently, there
has been renewed interest in the use
of intracameral SF6 and C3F8 gases,
which have been shown to lead to
Photo: Edward Boshnick, OD
orneal hydrops, an
uncommon complication seen in patients
with corneal ectatic
disorders, is characterized by the leakage of aqueous
through a tear in Descemet’s membrane, which leads to a rolling of
the edge and subsequent gaping of
the posterior surface of the cornea.
This allows the aqueous fluid to
intrude into the cornea, producing an acute edematous response,
relative changes in corneal architecture and clinical symptomatology. Patients typically present with
a rapid decrease in visual acuity,
photophobia and pain. There is
also notable localized edema and, in
some instances, visible ectasia in the
areas most compromised.
Corneal hydrops is estimated
to occur in 2% to 3% of patients
with keratoconus, with the majority presenting between ages 20 and
40. While some literature supports
an increased rate of occurrence in
males, there is no notable prevalence by race. In most cases, the
location of the hydrops is inferior to
the apex of the cone. When questioned, patients frequently admit
to significant eye rubbing. In some
instances, severe coughing and/or
heavy lifting have also been associated with onset of disease. Down’s
syndrome may be a risk as well.
Most cases heal naturally over
a period of several months when
treated using conservative methods,
which include topical cycloplegic
agents, corticosteroids to reduce
Fig. 1. Placement of intracameral
C3F8 (non-expansile concentration)
in a different patient than the one
described here. Note: the patient
was instructed to lie flat with their
eyes looking up towards the ceiling,
so that the gas can occlude the
break in the posterior cornea.
faster improvement compared to
more conservative treatments.1,2
Intrastromal venting incisions, used
to delimit the large vacuoles that
occur in some patients, have also
demonstrated some success but are
still relatively experimental. Overall, more research is needed on the
efficacy of these and other emerging
treatments.
CASE STUDY
A recent case of corneal hydrops
that presented to my office is emblematic of the conventional characteristics of the disease, and serves as
a good example of conservative vs.
more aggressive surgical treatment.
TW, a 42-year-old black female,
was initially seen for a complaint
of progressive change in visual
function relative to longstanding
keratoconus, and a recent history of
possible progression noted by her
current clinician. The consultation
identified significant apical scarring
in her right eye, and notably less
scarring in the left. The best-corrected visual acuity with spectacles was
20/300 OD, which did not improve
on pinhole, and approximately
20/80 OS with minimal pinhole
improvement. Her previous history
was positive for contact lens wear,
although discomfort as well as poor
acuity had decreased the patient’s
wearing activity to a minimal level
over the last six to 12 months.
The remainder of her examination elements (i.e., intraocular
pressure, lenticular assessment
and posterior pole) were relatively
normal. The patient was advised
that several options were available:
she could forgo intervention at this
time, be fit with a complex hybridtype or scleral contact lens with the
hope of achieving better results than
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3/27/15 3:42 PM
Photo: Edward Boshnick, OD
Fig. 2. Hydrops resolved.
her current standard hard lens, or
undergo a corneal transplant.
The patient elected to consider
the options and was scheduled
for another appointment in three
months, with plans to return sooner
if a decision was made. Approximately six weeks after her initial
evaluation, the patient contacted the
on-call service on a weekend and
indicated that she had developed
a notable decrease in vision, along
with severe pain and photophobia.
I saw her on the same day, and
it was evident she had a significant
corneal hydrops and a visible Descemet’s membrane tear. This was
accompanied by notable apical ectasia in the zone of the hydrops. The
presentation of the cornea was 3+/4
edema, focally located over the zone
of the hydrops, which consisted of
epithelial microcystic edema and intrastromal cysts and vacuoles. The
diameter of the area was approximately 4.5mm to 5.0mm. Visual
acuity was hand motion at two feet
with no pinhole improvement.
I discussed treatment options
with the patient, who elected to
proceed with conservative therapy,
which included a topical antibiotic
(ciprofloxacin) QID to prevent
infection, one drop of a cycloplegic
(atropine) BID, the use of a hypertonic saline ointment (Muro 128)
QID and an ocular antihypertensive agent to lower pressure and
decrease the posterior forces on the
cornea contributing to architectural
change. The patient was also placed
on topical Durezol QID, and a
bandage lens was inserted—primarily for comfort, but also to prevent
perforation.
The patient was observed over
several weeks and, as is typical
with hydrops, the intrastromal
edema that was present at the initial
episode began to resolve, as did the
photophobia. At the initial threeday follow-up, the pain had lessened significantly with the atropine
and Durezol, and the inflammatory
response present in the cornea
showed a mild decrease. Additionally, the pressure had been reduced
from 16mm Hg to 10mm Hg. The
patient’s bandage lens was removed
in order to view the corneal surface;
upon removal, a decrease in the
microcystic edema was observed
and the stromal vacuoles and clefts
appeared stable. I ordered current
medication levels be maintained,
but decreased the atropine to QD.
At the two-week follow-up, I
reduced the steroids to BID and
stopped the atropine. I continued
the antibiotics but reduced the
dose to BID. The bandage lens was
also removed at two weeks and
the cornea was competent with a
negative Seidel. The patient called
two days after the bandage lens was
discontinued and indicated that she
had developed a foreign body sensation, so I reinstituted lens wear. I
maintained her on the antihypertensive agents for approximately
four weeks. Additionally, she used
the hypertonic saline ointment four
times daily throughout the treatment period.
By the fourth week, the patient’s
vision had returned to 20/200
best-corrected in the affected eye.
Additionally, the microcystic edema
had reduced dramatically, and the
stromal edema had begun to demonstrate a coalescence of the vacuoles, which were notably present at
the initial clinical assessment.
It should be noted in cases like
this one that therapeutic options
like hybrid or scleral lenses are less
viable because of the scar formation, which is almost universal in
patients of this type following a
severe hydrops. I discussed the potential for a therapeutic penetrating
keratoplasty as the option of choice,
and TW is actively considering the
possibility once the eye stabilizes. I
anticipate that, given her current,
relatively poor visual rehabilitative
potential and the fact that the other
eye also shows notable keratoconus,
a penetrating keratoplasty would be
a reasonable option to rehabilitate
visual function and give her overall
better visual potential in the years
to come.
RCCL
1. Panda A, Aggarwal A, Madhavi P, et al. Management of acute corneal hydrops secondary to
keratoconus with intracameral injection of sulfur
hexachloride (SF6). Cornea. 2007;26(9):1067-9.
2. Basu S, Vaddavalli PK, Ramappa M, et al.
Intracameral perfluoropropane gas in the treatment of acute corneal hydrops. Am J Ophthalmol
2011:118(5):934-9.
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3/27/15 3:42 PM
Out of the Box
By Gary Gerber, OD
Are You a Mentalist?
Probably not. And neither are your staff members. Clear communication with your team
is key to the success of your practice.
I
f you’ve attended one of
my lectures at a meeting
or trade show, chances are
you’ve probably also seen
me do magic—specifically, a
type known as mentalism. Instead
of pulling a rabbit out of a hat,
mentalists use whatever is in the
imagination of their audiences to
complete their illusions. Mentalism is essentially magic of the mind
and frequently deals with predictions about the future. So, here’s a
prediction I’ll make for everyone
reading this article and, since you’re
reading it for the first time and I’m
not standing in front of you, there
is no possible way I could have set
this up in advance!
My prediction is that the
practice-building challenge you
encounter most frequently is—wait
for it—staff management. How’d I
do? (Email me, I’d love to know!)
And, the number one reason why
so many doctors struggle with staff
management is because they aren’t
mentalists. In other words, they
haven’t figured out how to predict
the future! But what’s the connection between understanding the
future and staff management?
While it’s likely most of us do
not know what our personal
futures hold, chances are many
of us have a good idea regarding
the future of our practice. And,
we have an obligation as practice
leaders and CEOs to communicate this future to our staff. Great
staff management and leadership
involves understanding the long
view and communicating that view
to your staff—something that isn’t
always easy.
34
AVOID MYOPIC LEADERSHIP
Due to the stresses and day-to-day
pressures of running a practice,
many of us succumb to “leadership myopia” and are only able
to focus on what is directly in
front of us at a given moment. As
with all behaviors, staff members
see your acute laser focus on the
“here and now” and assume that
if it’s important to you, it should
be important to them too. The
problem with this thought process
is that bigpicture goals,
practice values
and your very
reason for being a practice
can get lost in
this short-term
view. People are people, and patients are patients. You’ll always
have acute patient management
issues to deal with. Unless you routinely set aside uninterrupted time
to discuss with your staff why you
are doing what you do with each
patient on a day-to-day basis, they
will never adopt your long-term
view (i.e., your mentalist’s prediction, if you will) of the future.
Here’s an example: Mr. Late
runs into the office out of breath
and says, “I ran out of contact
lenses and I’m on my way to work.
Can I have one more pair to hold
me over?” As instructed at your
last staff meeting, your staff correctly checks his record and sees
that his last examination was 16
months ago. Your clinical recommendation is once per year. So,
the staff member says, “I’m sorry,
you’re overdue for your exami-
nation, so we can’t give you any
more lenses.”
Volumes have already been
written about what may or may
not happen next, and putting 10
of us in a room to discuss the best
course of action would make for
a nice fireside chat—or perhaps a
barroom brawl. However, what is
rarely discussed is how to put your
own view of how this situation
should be handled into the minds
of your staff.
“BIG PICTURE GOALS
AND PRACTICE VALUES
CAN GET LOST.”
What is your long-term, futuristic macro goal for your practice
and the micro short-term goal for
this particular patient? The policy
to deal with this individual patient
is already known to every practice
(i.e., either give the patient lenses
or don’t, with any necessary explanations or caveats) but the reason
for doing so, in the context of your
big picture practice vision, is rarely
articulated to staff. In other words,
“Give or don’t give the lenses
because our practice philosophy
and long-term goals are…” is not
usually discussed. This way, your
staff members are able to better
adhere to these long-term goals in
the face of such situations.
So, hone your mentalist skills
and start communicating your
goals and aspirations to your staff.
Your day-to-day operations will
run much smoother.
RCCL
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
034_RCCL0415_otb.indd 34
3/27/15 4:48 PM
All eyes deserve clariti.
clariti 1 day—now available for practices everywhere.
The world’s first and only family of silicone hydrogel daily
disposable contact lenses designed for every patient
type—sphere, toric and multifocal.
High Oxygen
Transmissibility
High Water
Content
Low
Modulus
UV
Protection
Affordable
Upgrade
Now you can prescribe all of your patients with healthy,
comfortable, affordable silicone hydrogel 1 day lenses—
which will make all eyes very happy indeed.
To learn more, contact your CooperVision representative
today or visit CooperVision.com/practitioner.
RO0115_Cooper Clariti.indd 1
12/22/14 11:42 AM
Hello Miru.
Bye, bye blister pack.
Introducing Miru 1day, the world’s thinnest package for daily disposable contact lenses.
Miru’s ultra lightweight 1mm thin package is about 1/8th the thickness of a traditional blister pack
>˜`Ü>ÃëiVˆwV>Þ`iÛiœ«i`̜Ài`ÕVi̅iÀˆÃŽœv“ˆVÀœLˆ>Vœ˜Ì>“ˆ˜>̈œ˜°7…i˜œ«i˜i`]̅i
lens is presented on a special disk, oriented correctly for proper insertion.
To learn more and request trials, please visit: miru.meniconamerica.com
©2014 Menicon America, Inc. Miru is a registered trademark of Menicon Company Ltd.
RCCL0315_Menicon.indd 1
2/23/15 11:15 AM